Search

Background: Fetoscopic endoluminal tracheal occlusion (FETO) improves lung maturation in severe cases of congenital diaphragmatic hernia (CDH) but it does not ameliorate lung compression by herniated abdominal organs. Surgically opening the fetal abdomen (abdominal decompression [AD]) reduces the intrathoracic pressure by diverting the abdominal organs into the amniotic cavity-a probable causal therapy for lung hypoplasia and pulmonary hypertension in CDH. Open surgical abdominal decompression has been reported: we describe a minimally invasive approach in an ovine model of CDH as a probable fetoscopic intervention. Materials and Methods: Eight fetuses were included, 2 were kept as HEALTHY controls. A CDH (left side, liver down) was created by open fetal surgery at midgestation in 6 fetuses, 2 were taken as CDH controls. Fetoscopic abdominal decompression (fAD) was performed 21 days later in 4 animals. The fetuses were retrieved at the end of gestation and evaluated by lung stereology. Results: fAD led to a near total evacuation of the thoracic cavity in 2 of the 4 animals. Fetuses with CDH had a lower total volume and fraction of alveolar air space, a lower volume fraction of the parenchyma, and an increase of the volume fraction of the alveolar septa and atelectasis, as well as an increased mean thickness of alveolar septa compared with HEALTHY fetuses. Fetuses treated with abdominal decompression showed an improvement of stereological parameters. Conclusions: In spite of relevant limitations (pilot study, small groups, spontaneous closure of the abdominal incision) we were able to demonstrate that abdominal decompression for CDH can be performed by fetoscopy. Our results support the hypothesis of causally improving lung development by abdominal decompression, thus implying increased survival in extreme cases of CDH. A refinement of the fetoscopic techniques and direct comparison to FETO appears warranted.

Study question Does the total cytoplasmic volume (TCV) of the zygote and time of pronuclei disappearance (tPNf) affect blastocyst development potential and blastocyst quality? Summary answer The total cytoplasmic volume of zygote and the time of pronuclei disappearance strongly affect blastocyst development as well as blastocyst quality. What is known already Extended embryo culture with blastocyst transfer is considered a useful method for selecting embryos with a high implantation potential. One of the main concerns in the German Embryo Protection Act is that the choice of embryos that have a high potential for successful implantation must be made at the pronucleus stage. The introduction of time-lapse technology enabled comprehensive information regarding the morphology and kinetics of the embryo. Although for the past years, strong correlations between embryo morphokinetics and positive outcomes have been demonstrated, some disagreement concerning the wide application of these parameters into an early-stage embryo selection is still present. Study design, size, duration The injection time of ICSI was designated as “time zero”, and computer software was used to calculate the time frame between the injection and the moment of pronuclei disappearance (tPNf). The total cytoplasmic volume was calculated 16–18 h after injection based on manually drawn diameters of the zygotes, by the computer. Obtained measurements were later associated with the blastocyst formation potential as well as with blastocyst quality. Participants/materials, setting, methods A total of 187 oocytes from 34 patients undergoing the antagonist cycle for ICSI treatment were evaluated. All blastocysts were cultured in Embryoscope™ according to the manufacturer’s specifications (Vitrolife, Sweden). The Gardner and Schoolcraft scoring system was used to describe blastocyst quality. Statistical analyses were performed using IBM SPSS version 24. Data were reported as median and range. Differences between groups were tested using the Mann-Whitney U test. Statistical significance was defined as p Main results and the role of chance Obtained data showed that the total cytoplasmic volume values were significantly higher in zygotes that reached the blastocyst stage compared with those that did not [708376,268µm³ (560564,412µm³ - 838602,605µm³) vs 674349,917 (415749,353- 823640,638) respectively; p Limitations, reasons for caution The limitation of the presented study was that due to the double-embryo transfer correlation between morphokinetic parameters and pregnancy rate was not possible to be calculated. Further research should link these morphokinetic parameters with pregnancy rate and live birth rate as well. Wider implications of the findings: The potential of the present findings is considerable, especially for countries with strict Embryo Law Regulation. Obtained results might be highly useful for selecting embryos with high implantation potential. In addition, the present work illustrates the possibility of additional information that can potentially be incorporated into an embryo classification model. Trial registration number Not applicable

Study question Does the spatial arrangement of blastomeres and the start of blastulation affect blastocyst quality? Summary answer Better blastocyst quality is associated with the spatial arrangement of the embryo and the shorter time frame of blastulation (cavitation). What is known already The ability to select the human embryo with the highest implantation potential remains one of the greatest challenges in the management of In Vitro Fertilization patients. Several publications have proposed that additional morphological evaluations of blastomere arrangement and the dynamics of late-stage embryonic divisions might be a useful non-invasive way for embryo selection. In the last decade, the introduction of time-lapse technology enables continuous monitoring of embryo development, which leads to better outcomes than a selection based on the traditional morphology assessment. Study design, size, duration The spatial arrangement was defined as tetrahedrally if the cleavage planes were perpendicularly orientated, while embryos with rather parallelly orientated cleavage axes were considered as non-tetrahedral embryos. The injection time of ICSI was designated as “time zero” (t0), and EmbryoViewer software was used to calculate the time duration between injection and start of blastulation (cavitation). Obtained results were later correlated with the embryo’s capability to form a blastocyst as well as with blastocyst quality. Participants/materials, setting, methods A total of 195 oocytes from 40 patients undergoing the antagonist cycle for ICSI treatment were evaluated. All blastocysts were cultured in Embryoscope™ according to the manufacturer’s specifications (Vitrolife, Sweden). The Gardner and Schoolcraft scoring system was used to describe blastocyst quality. Statistical analyses were performed using IBM SPSS version 24. Data were reported as median and range. Differences between groups were tested using the Mann-Whitney U test. Statistical significance was defined as p Main results and the role of chance Obtained data showed that 83.6% (61/73) of embryos with tetrahedral arrangement formed blastocysts compared to 42.4% (50/116) of embryos with the non-tetrahedral arrangement (p Limitations, reasons for caution The limitation of the present study was that due to the double-embryo transfer correlation between those morphokinetic parameters and pregnancy rate can not be calculated. Further research should link these morphokinetic parameters with pregnancy rate and live birth rate as well. Wider implications of the findings: The potential of our findings is considerable, especially for countries with strict Embryo Law Regulation. Obtained results might be highly useful for selecting embryos with high implantation potential. In addition, the present work illustrates the possibility of additional information that can potentially be incorporated into an embryo classification model. Trial registration number Not applicable

This prospective study was designed to investigate whether anti-Müllerian hormone (AMH) levels are associated with the presence of multiple pronuclei in zygotes as well as with the ovarian response, fertilization rate and pregnancy outcome in ICSI cycles. A total of 413 patients undergoing ICSI cycles were included in the study. The assessment included 3084 MII oocytes. Serum AMH measurements were performed at the first initial presence of the patient. The outcome measures were the presence of multiple pronuclei (PN), a number of retrieved oocytes, number of mature/immature oocytes, fertilization rate and clinical pregnancy. Obtained results showed a statistically significant correlation between AMH levels and maternal age, the number of follicles, the number of cumulus-oocyte complexes, mature and immature oocyte, fertilization rate and pregnancy rate. Linear regression analysis showed that AMH significantly correlates with the presence of multiple pronuclei in the zygote. The further analysis confirmed that the number of zygotes with the presence of multiple pronuclei increased when AMH levels were higher. This is the first examination of the prognostic value of the serum AMH on the presence of multiple pronuclei in the zygote and our data in the preliminary study suggest that AMH levels could be used as a predictive marker.

Summary The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.

Introduction Spaced learning has been shown to be superior in complex motor skill acquisition like laparoscopic suturing and knot tying. By using a pre–post follow-up design, the aim of the study was to evaluate the long-term impact of implementation of the spaced learning concept in laparoscopic training. Materials and Methods To evaluate the effectiveness of spaced learning, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes—prior and after 3 hours of hands-on training. To examine the long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 12 months later as follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation. Results Twenty students were included in the study; after simple randomization, 10 were trained using the “spaced learning” concept and 10 via traditional methods. Both groups had comparable baseline characteristics and improved after training significantly, regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of speed (p = 0.021), knot quality (p = 0.008), and suture strength (p = 0.003). Additionally, spaced learning significantly decreased anxiety (p = 0.029) and probability of success (p = 0.005). Conclusion The spaced learning concept is very suitable for long-term complex motor skill acquisition, like laparoscopic suturing and knot tying. It is superior to conventional training regarding speed and, most importantly, knot quality and stability, resulting in improved confidence and motivation. Thus, we strongly recommend to incorporate the spaced learning concept into training courses and surgical programs.

Background & Aims Hirschsprung’s disease (HSCR) is a congenital intestinal motility disorder defined by the absence of enteric neuronal cells (ganglia) in the distal gut. The development of HSCR-associated enterocolitis remains a life-threatening complication. Absence of enteric ganglia implicates innervation of acetylcholine-secreting (cholinergic) nerve fibers. Cholinergic signals have been reported to control excessive inflammation, but the impact on HSCR-associated enterocolitis is unknown. Methods We enrolled 44 HSCR patients in a prospective multicenter study and grouped them according to their degree of colonic mucosal acetylcholinesterase-positive innervation into low-fiber and high-fiber patient groups. The fiber phenotype was correlated with the tissue cytokine profile as well as immune cell frequencies using Luminex analysis and fluorescence-activated cell sorting analysis of colonic tissue and immune cells. Using confocal immunofluorescence microscopy, macrophages were identified in close proximity to nerve fibers and characterized by RNA-seq analysis. Microbial dysbiosis was analyzed in colonic tissue using 16S-rDNA gene sequencing. Finally, the fiber phenotype was correlated with postoperative enterocolitis manifestation. Results The presence of mucosal nerve fiber innervation correlated with reduced T-helper 17 cytokines and cell frequencies. In high-fiber tissue, macrophages co-localized with nerve fibers and expressed significantly less interleukin 23 than macrophages from low-fiber tissue. HSCR patients lacking mucosal nerve fibers showed microbial dysbiosis and had a higher incidence of postoperative enterocolitis. Conclusions The mucosal fiber phenotype might serve as a prognostic marker for enterocolitis development in HSCR patients and may offer an approach to personalized patient care and new therapeutic options., Graphical abstract

It is difficult to predict the risk of mortality in necrotizing enterocolitis (NEC). This study aimed at identifying risk factors for severe NEC (Bell stage III) and mortality in preterm children with NEC. In this multicenter retrospective study, we analyzed multiple data from 157 premature children with confirmed NEC in the period from January 2007 to October 2018. We performed univariate, multivariate, stepwise logistic regression, and receiver operator characteristics (ROC) analyses. We were able to demonstrate that low Apgar scores (notably at 1′ and 5′), low hemoglobin concentration (Hgb), and high lactate level at disease onset and during disease correlated with NEC severity and mortality (P Conclusion: Low Apgar scores, low Hgb, high lactate levels, and the presence of CHD or PDA correlated with severe NEC or mortality in children with NEC. What is Known:• It remains difficult to predict which infant that suffers from necrotizing enterocolitis at risk of death.• Several clinical and laboratory parameters tools to predict fatal outcome in NEC. What is New:• The following laboratory parameters were associated with the risk of death from NEC: Hemoglobin concentration, base excess and lactate level.• The following clinical variables were associated with the risk of death from NEC: Apgar scores, as well as the presence of congenital heart disease and patent ductus arteriosus.

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Background & AimsHirschsprung’s disease (HSCR) is a congenital intestinal motility disorder defined by the absence of enteric nervous cells (ganglia). The development of HSCR-associated enterocolitis remains a life-threatening complication. Absence of enteric ganglia implicates extramural innervation of acetylcholine-secreting (cholinergic) nerve fibers. Cholinergic signals have been reported to control excessive inflammation, but the impact on HSCR-associated enterocolitis is unknown.MethodsWe enrolled 44 HSCR patients in a prospective multicenter study and grouped them according to their degree of colonic mucosal cholinergic innervation using immunohistochemistry. The fiber phenotype was correlated with the tissue cytokine profile as well as immune cell frequencies using quantitative reverse-transcribed real-time polymerase chain reaction (qRT-PCR) of whole colonic tissue and fluorescence-activated cell sorting (FACS) analysis of isolated colonic immune cells. Fiber-associated immune cells were identified using confocal immunofluorescence microscopy and characterized by RNA-seq analysis. Microbial dysbiosis was analyzed in colonic patient tissue using 16S rDNA gene sequencing. Finally, the fiber phenotype was correlated with postoperative enterocolitis manifestation.ResultsWe provided evidence that extrinsic mucosal innervation correlated with reduced interleukin (IL)-17 cytokine levels and T-helper-17 (Th17) cell frequencies. Bipolar CD14high macrophages colocalized with neurons and expressed significantly less interleukin-23, a Th17-promoting cytokine. HSCR patients lacking mucosal cholinergic nerve fibers showed microbial dysbiosis and had a higher incidence of postoperative enterocolitis.ConclusionThe mucosal fiber phenotype might serve as a new prognostic marker for enterocolitis development in HSCR patients and may offer an approach to personalized patient care and new future therapeutic options. (www.clinicaltrials.gov accessing number NCT03617640)

We report the case of a 4-year-old female infant who developed ongoing deep dermal necrosis of the bilateral legs after jellyfish contact in Thailand. Stepwise radical debridement and vacuum assisted wound therapy seemed to be an effective strategy to prevent progressive soft tissue loss.

This is the cumulative technical report on the operative procedures and limitations of fetoscopic bag insertion, intestinal bag placement, and bag fixation to the fetus in a series of pilot studies in an ovine model for prenatal treatment of gastroschisis. In 24 German blackhead sheep, a surgically created gastroschisis was managed by fetoscopic placement of the extruded intestines into a bag. The bag was then fastened onto the fetal abdominal wall. Different materials (sterile gloves, latex condoms, laparosopic retrieval bags) and different fixation techniques (laparoscopic staplers, interrupted and continuous sutures) have been examined. The fetuses were retrieved and evaluated at the end of gestation. Uterine bag insertion was successful in 15 of 24 (62.5%) and intestinal bag placement in 10 of 15 available fetuses (66.6%). The main factor limiting fetoscopic procedures was chorioamniotic separation (CAS). Sterilized condoms provided the most appropriate type of bags and the V-Loc™ running suture, the most expedient type of fixation, which was achieved in 9 of the 10 fetuses (complete = 2, partially = 7) by using a three port access (5 mm and 2 × 3 mm). All bags were encountered completely or partially dislocated from the fetus at the end of gestation. Fetoscopic intestinal bag placement and fixation in gastroschisis technically demanding. None of the evaluated techniques led to permanent anchorage of the bag to the fetus. The development of specially designed instruments, bags and fixation methods is required to optimize this approach.

Objective To identify the signs that can help to differentiate torsion of the appendix testis (AT) and epididymitis and to establish the incidence of the various pathologic entities in boys with an acute scrotum. Materials and Methods A retrospective study was performed of the data from all boys treated at our institute from January 2008 to January 2012 for the diagnosis of an “acute scrotum.” The clinical and, if available, ultrasound findings were documented. Differences between groups were calculated using a chi-square test or analysis of variance and classification and regression tree analysis. Results A total of 241 boys with acute scrotal pain were included and underwent surgical exploration. Of the 241 boys, 163 (70%) had AT, 44 (18.5%) had epididymitis, 31 (13.3%) had testicular torsion, and 3 (1.3%) had idiopathic scrotal edema. The incidence of AT was significantly increased in the colder months (P = .01). We found that AT and epididymitis shared several aspects but differed regarding dysuria (epididymitis, P ≤.001), a painful epididymis on palpation (epididymitis, P = .028), increased epididymal echogenicity (epididymitis, P = .043), augmented peritesticular perfusion (epididymitis, P = .05), and a positive blue dot sign (AT, P

Objective To test the clinical and sonographic predictors of testicular torsion (TT) with the aim of reducing negative exploration rates. Patients and Methods We performed a prospective study of all boys treated for ‘acute scrotum’ at our institute between January 2001 and April 2012 and clinical findings were documented. If available, ultrasonography (US) was added to the diagnostic evaluation. A prediction of the diagnosis was based on clinical and sonographic features, and was followed by surgical exploration in all patients. Results A total of 104 patients were included in the 16-month period of the study. No single finding excluded TT. The clinical features (pain 55%. Ultrasound predictors alone were not able to identify all boys with TT. Conclusions It is safe to refrain from routine surgical exploration in every child with acute scrotum if the clinical score is applied, which results in a marked reduction of negative explorations. A reliable diagnosis could not be obtained based on US alone. As scrotal US is unpleasant for the child, we propose to refrain from this if the clinical score is positive. Patients with a negative clinical score are suitable candidates for US to establish and secure diagnosis.

Spaced learning has been shown to be effective in various areas like traditional knowledge or motor skill acquisition. To evaluate the impact of implementation of the spaced learning concept in laparoscopic training was the aim of this study. To evaluate the effectiveness of spaced learning, subjects were asked to perform four surgeon’s square knots on a bowel model prior and post 3 h of hands-on training. All subjects were medical students and novice in laparoscopic suturing. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan score), and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation. Twenty students were included in the study; after simple randomization, ten were trained using “spaced learning” concept and ten conservatively. Both groups had comparable baseline characteristics and improved after training significantly regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of suture performance, knot quality, and suture strength. Ultimately, spaced learning significantly decreased anxiety and impression of challenge compared to controls. The spaced learning concept is very suitable for complex motor skill acquisition like laparoscopic suturing and knot tying. It significantly improves laparoscopic performance and knot quality as shown by the knot score and suture strength. Thus, we recommend to incorporate spaced learning into training courses and surgical programs.

Introduction: The embryogenesis of gastroschisis is not completely understood. The aim of our study was to evaluate the impact of a simple abdominal wall defect versus a defect including eviscerated intestine or omentum for the development of gastroschisis in a fetal lamb model. Material and Methods: At mid-gestation (day 77) an abdominal wall defect was fetoscopically created with three different approaches in 19 German blackhead sheep. The intestine was eviscerated in 7 fetuses (group 1). The peritoneum was incised and a patch of the omentum pulled through the incision in 5 fetuses (group 2). In 7 fetuses (group 3) the skin and rectus muscle were incised until the peritoneum was visible. In this group, no abdominal contents were exteriorized and the peritoneum was left intact. A second fetoscopic procedure was performed 21 days later, assessing the condition and extension of eviscerated bowel. The fetus was retrieved by Cesarean section on day 132 and evaluated. Results: The second fetoscopy acting as a control for the creation of gastroschisis demonstrated eviscerated and inflamed intestine in all 3 groups. The amount of eviscerated intestine did not appear to depend on the size of the defect nor on its duration. Discussion: It appears that a simple incision of the abdominal wall with intact peritoneum is sufficient for the development of gastroschisis in a fetal sheep model. This finding may improve the understanding of the etiology of gastroschisis.

The aim of the current study was to investigate the role of promoter methylation of adenomatous polyposis coli (APC) and epithelial cadherin (E-cadherin) genes in endometrial tumorigenesis. The methylation status of both genes was investigated in 43 cases of normal endometrium, 21 simple hyperplasia, 17 atypical hyperplasia, and 86 endometrial carcinoma (EC). Additionally, the methylation pattern of both genes was analyzed in 24 primary ECs and their corresponding metastases. DNA methylation of the APC gene increased from atypical hyperplasia (23.5%) to endometrial carcinoma, reaching its highest level of 77.4% in early stage cancer (FIGO I and II) and decreasing stepwise to 24.2% in advanced stage carcinomas (FIGO III and IV). No methylation of APC was found in normal endometrium or simple hyperplasia. Methylation of E-cadherin was found only in EC (22.1%). The mean age of the patients with aberrant APC methylation was 68.8 years and was significantly higher compared to the mean age (60.9 years) of the patients without methylation of APC promoter (P = 0.02). APC promoter methylation significantly correlated with decreased protein expression of APC (P = 0.039), with increased expression of the Ki-67 proliferative marker (P = 0.006) and decreased metastatic potential (P = 0.002). There was no correlation between APC and E-cadherin methylation patterns and the other clinicopathologic features, nor with patient outcome. Our results suggest that hypermethylation of APC promoter region is an early event in endometrial tumorigenesis.

Objective The aim of this study was to investigate the role of p16 in tumorigenesis of endometrial carcinoma (EC). Methods Expression of p16 protein was analyzed using immunohistochemistry. The methylation status of p16 promoter region was determined by methylation-specific PCR. Deletion analysis of the p16 gene was performed by PCR-analyses. Results Aberrant protein expression of p16 was observed in 18 of 46 (39.2%) ECs and correlated significantly with p16 alterations, including gene deletions in 26 of 46 (56.5%) ECs and promoter hypermethylation in 8 of 46 (17.4%) ECs ( p p16 alterations from early stage (I–II) to advanced stage (III–IV) ECs was observed ( p =0.002). There was no significant correlation between p16 protein expression and the clinico-pathological features of EC. The development of metastases correlated significantly with the frequency of p16 alterations: p16 alterations were detected in 14 of 15 (93.3%) PTs with metastases and in only 18 of 31 (58.1%) PTs without metastases ( p =0.018). The genetic comparison of 15 primary ECs and their paired metastases revealed that in most of the cases the deleted region of p16 gene remains the same or becomes larger during the progression from primary tumor to its corresponding metastases. Conclusion Our results suggest that p16 alterations and particularly p16 gene deletions in ECs are associated with increased incidence of metastases.

Background Severe congenital diaphragmatic hernia (CDH) is prenatally managed by fetoscopic tracheal occlusion (FETO) to improve lung growth and maturation. As FETO is not able to reduce the pressure onto the developing lungs originating from the intestine growing into the thoracic cavity, fetal abdominal decompression may alleviate this pressure effect by directing the growing intestine into the amniotic cavity away from the lungs. Therefore, aim of this study was to establish an animal model for fetoscopic abdominal decompression in fetal sheep with CDH. Methods CDH was created surgically on day 75 of 145 day gestation in eight fetuses. 2-3 weeks later, an opening was created in the fetal abdomen by fetoscopic surgery. The fetuses were retrieved by cesarean section at the end of pregnancy and evaluated. Results Five fetuses with CDH were treated with fetoscopic abdominal decompression. Three fetuses with CDH were taken as controls. One fetus was lost after creation of the CDH and two other after creation of the abdominal defect. Preliminary sterological results showed that the septal thickness of the experimental group was smaller than in the CDH group. Conclusion This study demonstrates the general feasibility of fetoscopic abdominal decompression for diaphragmatic hernia in our new animal model. Although not statistically significant, the lungs of treated fetuses were larger and heavier than those of untreated controls. Our findings support the hypothesis of palliative fetal surgery for severe CDH compared to tracheal occlusion. More controlled animal trials are needed.

INTRODUCTION Aim of this study was to compare the short-term outcome of transumbilical laparoscopic-assisted (TULAA) with laparoscopic (LA) and open appendectomy (OA) in a case-control study. MATERIALS AND METHODS Our first 20 consecutive children with appendicitis treated with TULAA were matched to 20 patients treated with LA and OA, respectively. Matching criteria were age, sex, and the histology of appendicitis. The children were retrospectively evaluated for outcome, efficacy, and complications. RESULTS No significant differences between the groups were found, except that children operated by OA required less analgesics than children operated by LA and TULAA. DISCUSSION TULAA appears to be a safe procedure with no disadvantage except for postoperative pain, which needed a longer course of analgesics compared to OA. Whether TULAA has advantages over LA and OA has to be evaluated in larger prospective series.

Background Prospective data of transumbilically laparoscopic-assisted appendectomies (TULAA) is absent in the pediatric population. We therefore compared the midterm outcome of TULAA with open (OA) and laparoscopic (LA) appendectomies in children with appendicitis in a matched prospective study. Methods A total of 20 patients operated with TULAA were matched to 20 cases operated by LA and OA, respectively, according to sex, age, and histology of the resected appendix. All 60 children were evaluated during a 3-month follow-up visit. Results The subjective pain level after discharge, the rate of complications, and persistent painful wound as well as the duration of days refraining from school or kindergarten were similar in all three groups. The wound satisfaction was significantly higher in TULAA and LA. Children operated with TULAA had a faster return to full physical activity compared with OA. Conclusion Our data suggest that TULAA, LA, and OA have a similar outcome 3 months after surgery apart from cosmetic appearance of the wound and return to full physical activity in pediatric patients. Whether parental bias or the increased wound satisfaction act as confounders for early return to full physical activity should be evaluated in larger prospective randomized trials.

A pilot study was conducted to investigate the influence of electromagnetic fields in the short-wave range (3-30 MHz) radio transmitter signals on salivary melatonin concentration in dairy cattle. The hypothesis to be tested was whether EMF exposure would lower salivary melatonin concentrations, and whether removal of the EMF source would be followed by higher concentration levels. For this pilot study, a controlled intervention trial was designed. Two commercial dairy herds at two farms were compared, one located at a distance of 500 m (exposed), the other at a distance of 4,000 m (unexposed) from the transmitter. At each farm, five cows were monitored with respect to their salivary melatonin concentrations over a period of ten consecutive days. Saliva samples were collected at two-hour intervals during the dark phase of the night. As an additional intervention, the short-wave transmitter was switched off during three of the ten days (off phase). The samples were analyzed using a radioimmunoassay. The average nightly field strength readings were 21-fold greater on the exposed farm (1.59 mA/m) than on the control farm (0.076 mA/m). The mean values of the two initial nights did not show a statistically significant difference between exposed and unexposed cows. Therefore, a chronic melatonin reduction effect seemed unlikely. However, on the first night of re-exposure after the transmitter had been off for three days, the difference in salivary melatonin concentration between the two farms (3.89 pg/ml, CI: 2.04, 7.41) was statistically significant, indicating a two- to seven-fold increase of melatonin concentration. Thus, a delayed acute effect of EMF on melatonin concentration cannot completely be excluded. However, results should be interpreted with caution and further trials are required in order to confirm the results.

The pathogenesis of intestinal dysmotility in gastroschisis is not completely understood. Peel formation and disorganization of interstitial Cajal cells (ICC) have been proposed in humans. The aim of this study was to evaluate the impact of prenatal coverage of gastroschisis on gut inflammation and expression of ICC in a fetal lamb model. Twenty-one German blackhead sheep with an abdominal wall defect that was created fetoscopically on day 77 of 145 days gestation were used in this study. Intrauterine surgery with the aim to cover the defect was performed 3 weeks later; two fetuses were covered completely, 5 partially and 11 remained uncovered. Three fetuses without gastroschisis were used as controls. All fetuses were retrieved by cesarean section at day 135. Samples of the small intestine were stained with hematoxylin and eosin for histologic analysis of peel formation and serosal and muscular thickness. For ICC detection, immunohistochemistry using anti-CD117 (c-Kit) antibody was used. In all samples with exposure to amniotic fluid, peel formation and significantly decreased ICC were found. Complete coverage reduced peel formation and disorganization of ICC compared to uncovered animals almost to the level of controls. Peel formation and ICC derangement were significantly reduced by prenatal coverage of gastroschisis. Moreover, this animal model mimics the histopathological bowel changes as seen in human gastroschisis and may, therefore, be used for further research on the pathophysiology and fetal therapy of this malformation.

Impalement injuries are uncommon, especially in the pediatric population. Because of the rarity of these injuries, physicians may have difficulty recognizing and treating impalement injuries appropriately. Clinical findings are sometimes innocuous, but can be life threatening. Therefore, evaluation of suspected impalement injury should involve careful history and thorough physical examination, even if there is no evidence of trauma to the perineum. We report a very rare case of rectum perforation after transanal introduction of a broomstick with almost no clinical findings. Impalement injuries are difficult to recognize, and severity may not be reflected by their external appearance. To diagnose these injuries in time, it is important to use a well-organized workup. Language: en

We present the results of experiments studying droplet coalescence in a dense layer of emulsion droplets using microfluidic circuits. The microfluidic structure allows direct observation of shear-induced collisions and coalescence events between oil droplets dispersed in water. A mineral oil was chosen as the dispersed phase and a 9 wt% NaCl aqueous solution as the continuous phase. We determine the coalescence rate as a function of the droplet velocity and droplet concentration from image sequences measured with a high-speed camera. A trajectory analysis of colliding droplet pairs allows evaluation of the film drainage profile and coalescence time tc. From the coalescence times obtained for ten thousands of droplet pairs we calculate the coalescence time distributions for each set of experimental parameters, which are the mean droplet approach velocity 〈v0〉 and the mean dispersed phase fraction 〈φ〉. We discuss the potential of the procedure for the prediction of emulsion stability in industrial applications.

To explore the role of transforming growth factor-beta (TGF beta) isoforms and other growth-related genes during prostate morphogenesis in the mouse, we examined mRNA levels in fetal day 17 urogenital sinus, mesenchyme (UGM), and epithelium (UGE) as well as in the ventral, dorsal, and anterior lobes of the adult prostate. In addition, we used antiserum specific for extracellular TGF beta 1 in immunohistochemical studies to localize accumulation of the TGF beta 1 isozyme in the above tissues as well as those derived from fetal day 19 and neonatal mouse prostate. Differential patterns of expression in fetal and adult tissues were seen. TGF beta 1, -beta 2, and -beta 3 expression was substantially elevated in UGM compared to that in UGE, yet only TGF beta 1, not TGF beta 2 or TGF beta 3, mRNA levels were sustained in adult prostate tissues. High levels of accumulation of TGF beta 1 were demonstrated by immunohistochemistry in the mesenchymal compartment compared to those in the epithelial compartment throughout development. Interestingly, the highest levels of TGF beta 1 appeared in areas of active epithelial duct formation and delineated the mesenchymal architectural changes necessary for ductal network formation. Additional studies revealed that levels of mRNAs for other genes involved in tissue remodeling and growth were also elevated in UGM compared to those in UGE. Tissue plasminogen activator, urokinase plasminogen activator, androgen receptor, and c-myc mRNA levels were also elevated in UGM compared to UGE. Interestingly, whereas tissue plasminogen activator mRNA levels, like those of TGF beta 2 and -beta 3, were barely detectable in adult prostatic tissues, mRNA levels for urokinase plasminogen activator, androgen receptor, and c-myc were readily detected and expressed in a lobe-specific fashion. Overall, these data indicate that expression of TGF beta 1 isoforms and other growth-related genes is associated with mesenchymal cells in areas of active morphogenesis during prostate development and provide objective molecular and cellular information regarding mediators of mesenchymal-epithelial interactions in prostate.

We investigated the methylation status of mismatch repair gene hMLH1 in 80 primary human endometrial carcinomas (ECs) and in 30 metastatic lesions. It was correlated to the expression of hMLH1 protein, microsatellite instability (MSI) of ECs and to the well-known clinico-pathological variables of cancer. The hMLH1 promoter methylation was detected in 24 out of 64 (37.5 %) primary ECs but only in one out of 18 (5.6 %) metastatic lesions investigated. Promoter hMLH1 hypermethylation was found more often in early stage ECs and was associated with a decrease of hMLH1 protein expression immunohistochemically. An inverse relationship between hMLH1 expression and clinical stage of the disease was found (p = 0.048). Interestingly, there was a significant correlation between MSI and hMLH1 protein expression level (p = 0.042). MSI phenotype was found more often in EC metastases compared to the primary tumors (66.7 % vs 29.3 %; p = 0.039). However, neither hMLH1 promoter hypermethylation nor MSI was independent predictive factors for patient’s outcome. Using an in vitro model we showed that hMLH1 methylation is reversible. These data showed that hMLH1 methylation with a consequent protein decrease occurred early during EC tumorigenesis and may cause a MSI phenotype, which occurs relatively late. MSI may be an important mechanism supporting further the tumor progression. These findings may have importance for the specific chemosensitization of the primary tumors/metastases and can improve our understanding of endometrial carcinogenesis in humans.

Gastroschisis is a malformation consisting of an abdominal wall defect with eviscerated bowel. Its standard treatment is postnatal repositioning or temporary prosthetic bag placement. The aim of our study is to evaluate the feasibility of its fetoscopic management in a lamb model. At mid-gestation (day 75), gastroschisis was created in eight German blackhead sheep. A second fetoscopic procedure was performed on day 105, assessing the viability, extension, and potential for repositioning of eviscerated bowel. The fetus was retrieved by Cesarean section on day 132 and evaluated. In six fetuses gastroschisis could be successfully created and assessed with fetoscopy. Two fetuses were lost due to technical complications. Primary repair by repositioning the intestine into the abdomen was not possible because it grew into an inflammatory conglomerate too large for the small fetal abdominal cavity. Although technically demanding, we were able to produce and reassess six cases of gastroschisis by fetoscopy. As primary repositioning appears unfavorable, fetoscopic prosthetic bag placement may become an alternative.

Mouse prostate reconstitution is a useful model for studying the progression of ras + myc-induced carcinomas. When these oncogenes were introduced into both the epithelial and the mesenchymal compartments, poorly differentiated adenocarcinomas resulted. Restricted introduction of both oncogenes into the epithelium produced epithelial hyperplasia. Malignancies were produced in two out of 17 cases of selectively transformed epithelium, suggesting that the hyperplastic condition represents a premalignant phenotype. Restricted introduction of both oncogenes into the mesenchyme produced only mesenchymal dysplasia. Transforming growth factor-beta 1 (TGF-beta 1) and beta 3 (TGF-beta 3) mRNA levels were elevated in the ras + myc-induced carcinomas when compared to the normal controls or to the epithelial hyperplasias. In contrast, TGF-beta 2 mRNA levels were similar in all control and ras + myc-induced carcinomas. Elevated TGF-beta 1 mRNA levels were also found in mesenchymal dysplasia pointing to a potential paracrine activity by the ras + myc transformed mesenchyme. We conclude that elevated TGF-beta 1 and beta 3 are correlated with progression to malignancy and that mesenchyme derived TGF-beta 1 may play an important role in the promotion of ras + myc-induced carcinomas in this model system.

Because the study of human IgE synthesis and regulation requires exquisitely sensitive and rapidly performed methods for assay of in vitro IgE production, we compared 4 methods for radiometric immunoassay (RIA) of human IgE: double antibody RIA (DARIA), ultrasensitive enzymatic RIA (USERIA), sensitive paper radioimmunosorbent test (SPRIST) and microtiter solid-phase RIA (MSPRIA). IgE protein was measured in serum samples and cord bloods. The USERIA and the MSPRIA consistently detected levels of IgE as low as 27–35 pg/ml. The DARIA and SPRIST were less sensitive. Comparison of the USERIA and the MSPRIA favored the latter because: (1) it is a more rapidly performed assay, (2) it involves fewer manipulations, and (3) it has less variability. We conclude that the MSPRIA for IgE is superior to the other methods both as a research tool for measuring minute quantities of IgE protein (as in tissue culture supernatants) and for measuring IgE in serum samples where concentrations fall below 1 ng/ml (0.42 IU/ml; 1 IU = 2.4 ng).