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Following the promising multicenter randomized trial results of in utero fetal myelomeningocele repair; we anticipate that an increasing number of tertiary care centers may want to offer this therapy. It is essential to establish minimum criteria for centers providing open fetal myelomeningocele repair to ensure optimal maternal and fetal/pediatric outcomes, as well as patient safety both short- and long-term; and to advance our knowledge of the role and benefit of fetal surgery in the management of fetal myelomeningocele. The fetal myelomeningocele Maternal-Fetal Management Task Force was initially convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development to discuss the implementation of maternal fetal surgery for myelomeningocele. The decision was made to develop the optimal practice criteria presented in this document for the purpose of medical and surgical leadership. These criteria are not intended to be used for legal or regulatory purposes. [ABSTRACT FROM AUTHOR]

Abstract: Background: We have previously shown that there is synergism between Hepatocyte Growth Factor (HGF) and Omega-3 (OM-3) enriched feeds using an immunologic model of inflammatory bowel disease (IBD). This combination decreased inflammation and cytokine levels and increased microvascular density and mucosal mass. This study evaluates the gene alterations that occurred using this same model. Methods: Twenty adult female transgenic HLA-B27 rats were divided into four groups: Group 1: (Regular feeds, IV saline); Group 2: (OM-3 feeds, IV saline); Group 3: (Regular feeds, IV HGF 150μg/kg/day); Group 4: (OM-3 feeds, IV HGF 150μg/kg/day). Rats were sacrificed 14days after pump placement. Bowel was harvested and RNA extracted. Microarray gene chips were used. Statistical analysis was done by analysis of variance using Partek Genomics Suite. Results were significant if fold change was more than 2 or less than −2, with P<0.05. Results: In the ileum, HGF up- or down-regulated 34 genes, while OM-3 affected 60 genes. Together 68 genes were affected. Families with a synergistic effect included Solute Carrier Proteins, ATP Binding Cassette Proteins, and Matrix Metalloproteinases. In the colon, 23 genes were affected by HGF, while 66 genes were affected with OM-3. Combined exposure affected 32 genes, including a synergistic effect on solute carrier proteins, aquaporins, and immunologic factors. Conclusions: There is a synergistic gene alteration effect of exposure of two (HGF and Omega-3 enriched feeds) agents on bowel mucosa. Of most interest was the synergistic effect on the solute carrier protein family, a previously identified gene family up-regulated in response to intestinal failure. [Copyright &y& Elsevier]

Abstract: Background: The management of lymphangiomas in children is a complex problem with frequent recurrence and infection. Vacuum-assisted closure (VAC) devices have been shown to accelerate the healing of open wounds. We hypothesized that VAC therapy might decrease complications after resection of lymphangiomas. Methods: A retrospective review was performed on 13 children (August 2005 to April 2010) who were patients undergoing lymphangioma resection with postoperative VAC therapy. Patient demographics, size and location of the lymphangioma, VAC duration and number of changes, hospital stay, complications, need for further surgery, and length of follow-up were recorded. Results: Thirteen children (mean age, 8 years; mean weight, 34 kg) underwent 15 operations for lymphangiomas followed by postoperative VAC therapy. Locations included the head and neck, thorax and abdomen, and lower extremity. The mean VAC duration was 19 days, and they underwent a mean of 2.6 VAC changes. Six children had operative closure of the wound at a mean of 15 days postoperative. The remaining patients underwent closure by secondary intention. There were no recurrences. Complications included VAC device malfunctions requiring intervention and wound infections. Mean follow-up was 289 days. Conclusion: Postoperative VAC therapy for the treatment of lymphangiomas can be an effective adjunct to surgical treatment by decreasing risks of recurrence and infection. [Copyright &y& Elsevier]

Abstract: Background: Hepatocyte growth factor (HGF) decreases intestinal inflammation and cytokine levels in an animal model of inflammatory bowel disease (IBD). Luminal omega-3 (OM-3) is anti-angiogenic, reduces inflammation, and may decrease symptoms in patients with Crohn''s disease. This study evaluates the synergism of HGF and OM-3. Methods: Twenty adult female transgenic HLA-B27 rats were divided into 4 groups: group 1: regular feeds, IV saline; group 2: OM-3–enriched feeds, IV saline; group 3: regular feeds, IV HGF (150 µg/kg per day); and group 4: OM-3–enriched feeds, IV HGF(150 µg/kg per day). Rats were killed at 14 days after pump placement. Small and large bowel mucosa was harvested, and DNA and protein were extracted and quantified. Statistical analysis was done by analysis of variance with post-hoc Tukey''s HSD test. Results: Content of protein and DNA in the ileum were significantly increased by supplementation of HGF (P < .001, P < .01, respectively) alone. OM-3 significantly increased protein content but not DNA (P = .02, P = 0.3, respectively). Combined, they had a synergistic effect greater than either supplement alone (P = .0001, P = .002, respectively). In the colon, HGF and OM-3 did not significantly increase protein or DNA content individually or together. Conclusions: This is the first demonstration of the synergistic effect of a growth factor (HGF) and a dietary supplement (OM-3) in an immunologic model of IBD. [Copyright &y& Elsevier]

Abstract: The discussions on health care reform over the past two years have focused on cost containment while trying to maintain quality of care. Focusing on just cost and quality unfortunately does not address other very important factors that impact on our health care delivery system. Availability of a well-trained workforce, maintaining the sophisticated medical/surgical education system, and ultimately access to quality care by the public are critical to maintaining and enhancing our health care delivery system. Unfortunately, all five of these components are under at risk. Thus, we have evolving the ultimate perfect storm affecting our health care delivery system. Although not ideal and given the uniqueness of our population and their expectations, our current delivery system is excellent compared to other countries. However, the cost of our current system is rising at an alarming rate. Currently, health care consumes 17% of our gross domestic product. If our system is not revised this will continue to rise and by 2025 it will consume 48%. The dilemma, given the current state of our overall economy and rising debt, is how to address this major problem. Unfortunately, the Affordable Care Act, which is now law, does not address most of the issues and the cost was initially grossly under estimated. Furthermore, the law does not address the issues of workforce, maintaining our medical education system or ultimately, access. A major revision of our system will be necessary to truly create a system that protects and enhances all five of the components of our health care delivery system. To effectively accomplish this will require addressing those issues that lead to wasteful spending and diversion of our health care dollars to profit instead of care. Improved and efficient delivery systems that reduce complications, reduction of duplication of tertiary and quaternary programs or services within the same markets (i.e. regionalization of care), health insurance reform, and tort reform collectively could save hundreds of billion dollars per year! These changes may not be easy to accomplish politically but will be essential to save what is likely the best health care system in the world. [Copyright &y& Elsevier]

Abstract: Purpose: Previously, we investigated the physiologic effects of hepatocyte growth factor (HGF) on intestinal adaptation using a massive small bowel resection (MSBR) rat model. To correlate these altered physiologic changes with gene alterations, we used microarray technology at 7, 14, and 21 days after MSBR. Methods: Forty-five adult female rats were divided into 3 groups and underwent 70% MSBR, MSBR + HGF (intravenous 150 μg/kg per day), or sham operation (control). Five animals per group were killed at each time point. Ileal mucosa was harvested and RNA extracted. Rat Gene Chips and Expression Console software (Affymetrix, Santa Clara, CA) were used. Statistical analysis was done by analysis of variance using Partek Genomics Suite (Partek, Inc, St Louis, MO). Results were significant if fold change was more than 2 or less than −2, with P < .05. Results: Compared with the control group, MSBR group had significant increases in up-regulated and down-regulated genes. The MSBR-HGF group had further increases in up-regulated and down-regulated genes compared with the MSBR group. At 7 days, 6 cellular hypertrophy families had 30 genes up-regulated, and HGF up-regulated an additional 14 genes. At 21 days, 5 hyperplasia gene families had 32 up-regulated genes. Hepatocyte growth factor up-regulated an additional 16 genes. Conclusions: Microarray analysis of intestinal adaptation identified an early emphasis on hypertrophy and later emphasis on hyperplasia. This is the first demonstration that the effect of HGF on intestinal adaptation is recruitment of more genes rather than an increase in the fold change of already up-regulated genes. [Copyright &y& Elsevier]

Abstract: Introduction: The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population. Methods: The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean ± SEM. Results: Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 ± 0.4 vs 6.1 ± 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 ± 0.05 vs 0.55 ± 0.08 mg/kg, P = .007). Operation times (111 ± 5 [open] vs 113 ± 5 minutes, P = .76) and estimated blood loss (13 ± 2 [open] vs 11 ± 1 mL, P = .33) were comparable for both groups. Conclusion: Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population. [Copyright &y& Elsevier]

Abstract: Purpose: Dependence on total parenteral nutrition in intestinal failure or short bowel syndrome patients can lead to many complications. The most significant complication is progressive liver injury leading to liver failure. This study assesses the potential of hepatocyte growth factor (HGF) in modulating the hepatic response in a rat cholestatic liver injury model. Methods: Female Sprague-Dawley rats were divided into 3 groups: control (n = 5), chronic liver injury (α-naphtylisocyocyanate [ANIT] every 3.5 days at 75 mg/kg; n = 5), and chronic liver injury plus HGF (ANIT + HGF at 250 μg kg−1 d−1; n = 5). The rats initially underwent massive (80%) small bowel resections. Seven days later, they were given intraperitoneal injections of saline (control) or ANIT and implantation of an osmotic minipump for continuous intravenous saline or HGF. Intraperitoneal saline or ANIT injections were subsequently administered every 3.5 days to create a chronic cholestatic model. After 14 days, the animals were euthanized, and liver biopsies were obtained. The liver biopsies were evaluated by histology, immunofluorescence staining for interleukin-6 and tumor necrosis factor α, and assessment of apoptosis by terminal dUTP-transferase-mediated nick end labeling (TUNEL) technique. Results: In this chronic liver injury model, HGF did not effect the grade of inflammation. However, HGF did induce retention of the ductal structures and avoided ductal proliferation, damage, and evidence of primary sclerosing cholangitis (P < .05). Hepatocyte growth factor induced less interleukin-6 (P < .011) and tumor necrosis factor α (P < .01) expression. Apoptotic activity was also significantly less in the HGF group (P < .01). Conclusion: Hepatocyte growth factor preserved the hepatic ductal system, modulated the hepatic inflammatory response, and reduced the apoptotic index in this chronic cholestatic liver injury model. It may diminish or prevent liver damage in patients with total parenteral nutrition–induced liver injury. [Copyright &y& Elsevier]

Abstract: Background/Purpose: The major side effect of total parenteral nutrition is liver injury leading to liver failure. This study was designed to assess specific growth factors in modulating the hepatic response in an ANIT-induced liver-injury model. Methods: Sprague-Dawley rats were divided into four groups: control (n = 5), liver-injury control (α-naphtylisocyocyanate [ANIT], 100 mg/kg, n = 8), ANIT + epidermal growth factor (EGF, 150 μg/kg per day, n = 10), and ANIT + hepatocyte growth factor (HGF, 250 μg/kg per day, n = 9). Rats were given intraperitoneal injections of saline (control) or ANIT and implantation of an osmotic mini-pump for 7 days of continuous intravenous saline (liver injury control), EGF, or HGF. Seven and 14 days later, liver biopsies were obtained and evaluated for interleukin (IL)–6 and tumor necrosis factor α expression by immunofluorescent staining, and for apoptosis, by the terminal transferase dUTP nick end labeling (TUNEL) technique. All animals were euthanized at 14 days. Results: Epidermal growth factor (P < .025) and HGF (P < .001) groups induced less IL-6 expression at day 14 compared to liver-injury controls. In addition, the interval decrease in IL-6 expression between days 7 and 14 was greater in EGF (P < .001) and HGF (P < .001) groups compared to liver-injury controls. At day 14, HGF also demonstrated decreased tumor necrosis factor α expression (P < .005). Apoptotic activity was significantly less for the EGF (P < .011) and HGF (P < .0012) groups. Conclusion: Epidermal growth factor and HGF modulated the hepatic inflammatory response and apoptotic index in this established liver-injury model and may diminish or prevent liver damage in patients with total parenteral nutrition–induced liver injury. [Copyright &y& Elsevier]

Abstract: Background: The administration of hepatocyte growth factor (HGF) during intestinal adaptation is known to enhance intestinal adaptation. Glucagon has also been implicated as a potential mediator of intestinal adaptation. Previous studies have shown that HGF and glucagon synergistically increase the proliferation of hepatocytes. HGF has also been shown to be preferentially expressed within the glucagon-positive cells of the pancreas, possibly indicating a paracrine or endocrine effect of HGF on glucagon. This study was designed to determine if HGF stimulation in the small intestine during intestinal adaptation influenced mucosal glucagon expression. Methods: Adult male Sprague-Dawley rats were randomized to either a 70% massive small bowel resection group (MSBR) or an HGF-treated MSBR group (MSBR-HGF). Seven days after surgery, HGF was administered intravenously at 150 μg/kg per day for 14 days. At day 21, the ileal and jejunal mucosa was harvested. The RAE 230A GeneChip (Affymetrix, Santa Clara, Calif) and MAS5 software were used to determine alterations in gene expression in the small intestine mucosa. Immunofluorescent staining of the ileal and jejunal mucosa using an antiglucagon antibody was performed and evaluated qualitatively. Results: The MSBR-HGF group had significantly greater protein and DNA content (P < .05) than the MSBR group. Glucagon gene expression in the MSBR-HGF group was decreased compared with the MSBR group, and immunohistostaining for glucagon in the ileum revealed no difference in intensity between the 2 groups. However, the jejunal MSBR-HGF group demonstrated significantly greater glucagon immunoreactivity than the jejunal MSBR group. Conclusion: Our data suggest that the HGF-induced increase in glucagon availability is disassociated from glucagon gene up-regulation. Thus, HGF may not only enhance intestinal adaptation directly, but also indirectly by increasing the “local” availability of other growth factors in the absence of their gene up-regulation. [Copyright &y& Elsevier]

Abstract: Background/Purpose: The mechanisms that control intestinal adaptation remain unknown. To better understand the adaptive process, microarray technology was used to analyze gene expression in a rat model of intestinal adaptation. Methods: Adult male Sprague-Dawley rats underwent either a massive small bowel resection (70%) with anastomosis or a sham operation with small bowel transection and reanastomosis. After 21 days, ileal mucosa RNA was extracted. Individual RNA samples (n = 5 per group) were labeled and hybridized to 10 separate RAE 230A rat GeneChips. The signal values were calculated and the 2 groups were compared using a t test with the multiple testing correction of Benjamini and Hochberg (false discovery rate of 10%). Probe sets were analyzed for overrepresented physiologic pathways using Expression Analysis Systematic Explorer (EASE). Results: Of the 15,866 probe sets on the RAE 230A GeneChip, 5437 probe sets were unexpressed and excluded. Of the remaining 10,429 probe sets, several overrepresented pathways (EASE score <0.01 after Bonferroni correction) were identified. Further analysis revealed that 13 probe sets related to proteasome degradation (an enzyme complex implicated in the regulation of cell proliferation) were significantly upregulated in the intestinal adaptation group compared to the sham group. Conclusions: Proteasomes may play a critical role in regulating the proliferation of intestinal mucosa during intestinal adaptation. [ABSTRACT FROM AUTHOR]

This study was designed to investigate the benefits of administration of hepatocyte growth factor in a rat model of inflammatory bowel disease. Transfection of the HLA-B27 gene into Fisher rats induces a phenotype similar to inflammatory bowel disease. Fisher rats and HLA-B27 rats were divided into six groups: (1) Fisher, intravenous saline; (2) HLA-B27, intravenous saline; (3) HLA-B27, intravenous hepatocyte growth factor; (4) Fisher, luminal saline; (5) HLA-B27, luminal saline; and (6) HLA-B27, luminal hepatocyte growth factor. Rats received a 14-day infusion through an osmotic pump attached to a catheter positioned in either the jugular vein or the terminal ileum. Rats were evaluated for stool character, and gross and microscopic bowel inflammation. Statistics were analyzed using analysis of variance or the Kruskal-Wallis nonparametric test. A value of P<0.05 was significant. Compared to untreated HLA-B27 rats, intravenous administration of hepatocyte growth factor decreased diarrhea by 41% and microscopic inflammation by 54% (P<0.05). Luminal hepatocyte growth factor exposure decreased total bowel lesions by 53% and microscopic inflammation by 40% compared to untreated HLA-B27 rats (P<0.05), but it did not have an effect on diarrhea. Administration of hepatocyte growth factor ameliorates many of the features of bowel disease in this rat model and theoretically could have therapeutic applications in the management of inflammatory bowel disease in humans. [Copyright &y& Elsevier]

Abstract: Purpose: Although laparoscopic pyloromyotomy is considered to be a clean case, many surgeons administer prophylactic preoperative antibiotics. The aim of this study was to evaluate the impact of prophylactic antibiotics on the wound infection rate after laparoscopic pyloromyotomy. Methods: We conducted a retrospective review of all patients who underwent laparoscopic pyloromyotomy at our institution between August 2002 and December 2009. Data included patient age, sex, weight, serum HCO3 at admission and at operation, and if the patient received prophylactic antibiotics. The rate of wound infection or other wound complications, including suture granuloma, umbilical granuloma, umbilical hernia, skin dehiscence, and omental evisceration, was determined. Results: Two hundred ninety-nine patients underwent 301 consecutive laparoscopic pyloromyotomies. Sixty-four percent (n = 194) of patients returned for follow-up and were included in the study. Fifty-seven percent (group A, n = 111) received antibiotics, and 43% (group B, n = 84) did not. There were 3 wound infections in each of the equally matched groups (group A, 2.7%; group B, 3.5%; P = .73). Other wound complications occurred in 4.5% of patients (n = 5) in group A and 8.3% of patients (n = 7) in group B (P = .27). Conclusion: The use of prophylactic antibiotics does not significantly decrease the rate of wound infection or other wound complications after laparoscopic pyloromyotomy. [Copyright &y& Elsevier]

Abstract: Ovarian sex cord stromal tumor (OSCST), sclerosing type, is an extremely rare ovarian tumor. Sex hormone production by OSCST can result in isosexual or heterosexual precocious puberty in younger patients. We present a case of a 7-month-old female infant found to have a sclerosing-type OSCST that presented with vaginal bleeding and very prominent vellus hair at the mons pubis. This represents the youngest patient reported in the literature with this subset of OSCST. [Copyright &y& Elsevier]