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• W2014768996 abstract "Intestinal atresia is a well-known neonatal intestinal disease. In this disease, the proximal dilated segment is usually anastomized to the distal one by some type of surgery during the neonatal period (1). However, in some patients a sufficient resection of the proximal segment cannot be obtained, and the proximal segment sometimes continues to be severely dilated with hypoperistalsis, even though a small amount of content is still able to pass through the anastomosis (2,3). Therefore, if a sufficient resection of severely dilated proximal segment cannot be performed, then alternative techniques, such as intestinal plication or tapering, are recommended (2,3). In the proximal dilated segment of intestinal atresia, abnormalities are sometimes recognized in the distribution of interstitial cells of Cajal (ICCs), as well as in the neuronal components and intramural smooth muscle cells (4–9). However, the chronological changes of such intramural components have not yet been fully investigated. In addition, as far as we know, in intestinal atresia cases who continued to be observed because of a severe dilation of the proximal segment, the chronological changes of ICCs have never been previously reported. We report the chronological changes in the intramural components, including ICCs, in a Japanese girl demonstrating severe dilatation in the proximal segment with hypoperistalsis after undergoing end-to-back anastomosis for the treatment of jejunal atresia (JA). CASE REPORT A 0-day-old Japanese girl, with a birth weight of 1.95 kg, was vaginally delivered after the onset of premature labor at 34 weeks' gestation. Polyhydramnios and double bubble sign in the fetal abdomen had been detected by ultrasonography at 26 weeks' gestation. She was thus suspected to have either duodenal atresia or JA. Apgar score was 2 and 5 at 1 and 5 minutes after birth, respectively, because of the aspiration of amniotic fluid. Thereafter, she was transferred to our department because of suspected duodenal atresia or JA. At admission, a slight upper abdominal distension was found. The laboratory findings were normal. Abdominal plain radiograph film showed a double bubble sign, and abdominal ultrasonography showed a severe dilatation of the third portion in the duodenum. Brain ultrasonography revealed bilateral periventricular echogenicity. However, no abnormalities were identified based on a chromosomal analysis. A laparotomy was performed at 2 days after birth. The operative findings showed JA at 5 cm distal to the third portion of duodenum (Louw III b type), with severe proximal dilatation and a nonrotation-type malrotation. The diameters of the proximal and distal jejunum were 30 and 6 mm, respectively. Therefore, the proximal jejunum was anastomosed to the distal one in an end-to-back fashion. The postoperative course was uneventful. However, most of the required energy intake was provided by a combination of parenteral and enteral nutrition using a feeding tube that passed the anastomosed site of the first operation because the passage of the anastomosis was insufficient. At 1.5 and 4 months of age, contrast studies showed no improvement in the medium passage through the anastomosis with a markedly dilated proximal jejunum. As a result, reoperation was performed at 6 months of age. The diameters of the proximal and distal segments around the primary anastomosis were 40 and 8 mm, respectively. A partial resection of the dilated proximal segment and a tapering of the residual proximal one were done, while also anastomosing the proximal tapered end to the distal jejunum. The patient's energy intake had gradually increased through tube feeding because of the improvement in the passage of milk through the anastomosis. A postoperative contrast study showed an improvement in the medium passage through the anastomosis. However, dysphagia also continued to be a problem because of cerebral paralysis. Therefore, a gastrostomy was performed at 10 months of age. Thereafter, the required energy intake continued to be provided by the gastrostomy. She was discharged at 11 months of age and has since been followed up in our department. IMMUNOHISTOCHEMICAL METHODS AND FINDINGS Both the proximal and distal jejunal samples were obtained at the primary and second operations (2 days and 6 months after birth). In addition, control tissues of jejunum were obtained from 4 patients without gastrointestinal disease at either autopsy or during a radical operation (neonatal controls: congenital diaphragmatic hernia, 2 cases at ages 1 day and 14 days; infant controls: congenital biliary dilatation, 2 cases at age 6 months). To evaluate the chronological change in the intramural components in our case, the intramural components were investigated using immunohistochemical methods in addition to investigations by hematoxylin and eosin staining. Then they were also compared with those of the controls. All of the specimens were stained using the standard strepto-avidin-biotin method with a monoclonal antibody to α-smooth muscle actin (α-SMA, clone 1A4, diluted 1:3000, Sigma Immunochemicals, St Louis, MO) as a general muscular marker, polyclonal antibodies to neuronal specific enolase (NSE, code No. 422081, Nichirei, Tokyo, Japan) as a general neuronal marker, and antibodies to c-kit protein (CD-117, diluted 1:50, Dako Cytomation, Carpinteria, CA) as a marker of intestinal cells of Cajal. Hematoxylin and eosin staining showed a decrease of both myenteric and submucosal ganglia in both number and size, and an increase in the thickness of muscle layers in the proximal segment obtained from the first operation (data not shown). In the proximal segment obtained from the second operation, an improvement of both ganglia in both number and size was found, but the hypertrophic muscle layers were still present (data not shown). In addition, some small round cells were infiltrated in the muscle layers in proximal samples obtained in both operations. In contrast, the distal segments in both samples showed that the findings in both ganglia and muscle layers were similar to those in controls (data not shown). Regarding neuronal innervation, a decrease of number in NSE-positive cells was found in both myenteric and submucosal ganglia of the proximal segment obtained from the first operation (Fig. 1A) compared with that of neonatal controls (Fig. 1B). In addition, the distribution of nerve fiber in both circular and longitudinal muscle layers was decreased compared with that in neonatal controls (Fig. 1A, B). However, an improvement of the numbers in the decrease of neuronal cells was recognized in all of the layers, especially in the myenteric ganglia and the hypertrophic muscle layers, of the proximal segment during the second operation by the NSE staining (Fig. 1C). The distribution of neuronal cells also was similar to that of the infant controls (Fig. 1D). In contrast, the increase in the number of nerve fibers in the hypertrophic muscle layers, especially in the circular muscle layer, in the proximal segment on the second operation was recognized (Fig. 1C) compared with that of infant control (Fig. 1D). The neuronal distributional pattern in the distal segments obtained from both the first and second operations was equivalent to that of the age-matched controls.FIG. 1: Neuronal distribution in the proximal segments of jejunal atresia and the jejunum of age-matched controls (original magnification, ×100). The neuronal specific enolase staining in the proximal segment was obtained from the (A) first and (C) second operations. The decrease in both positive cells and fibers was found in the first operation, compared with (B) the distribution of neonatal controls. However, the decrease in neuronal cells improved on (C) the second operation. In contrast, an increase of nerve fiber distributed in the muscle layers was found on the second operation, compared with that of (D) age-matched infant controls.Staining with α-SMA showed positive areas in both the circular and longitudinal musculature and an increase in the proximal segment obtained from both operations, in comparison with that of age-matched controls. In the distal segments obtained from both operations, the positive area for α-SMA antibody was similarly distributed to that of age-matched controls. Concerning the distribution of ICCs, a decrease in the number of c-kit positive cells in the proximal segment obtained from the first operation was recognized around the myenteric plexus (Fig. 2A) compared with the age-matched controls (Fig. 2B). The ICCs at the deep muscular plexus were not found in either the proximal segment of the first operation or the neonatal controls. The positive cells had a spindle shape in the sample obtained from the first operation, but some of the positive cells in the neonatal controls demonstrated a branched shape. Strikingly, the distribution pattern found in the proximal segment obtained from the first operation remained unchanged in the proximal segment obtained from the second operation (Fig. 2C). The number of positive cells was thus apparently less than that of the age-matched controls (Fig. 2D). The positive cells in the proximal segment obtained from the second operation were still spindle shaped, but age-matched controls were almost all branch shaped. The distribution of positive cells in the distal segments obtained from both operations was similar to that of age-matched controls.FIG. 2: Interstitial cells of Cajal (ICC) distribution in the proximal segment of jejunal atresia and the jejunum of age-matched controls (original magnification, ×100). A small number of ICCs, which were positive for c-kit antibody, was found around the myenteric plexus in the (A) proximal segment obtained from the first operation. The number of ICCs was similar to that in the (C) sample obtained from the second operation. In comparison to the (B) neonatal controls, a clear decrease was observed in the number of ICCs in the proximal segment obtained from the first operation. Similarly, the number of ICCs on the second operation also was apparently less than that of (D) infant age-matched controls.DISCUSSION In this case, the striking findings were that neither the decrease in the number of ICCs nor the hypertrophy of muscular layers improved after the first anastomosis, despite an improvement in the decreased intramural neuronal components. In this case, a small volume of enteral nutrition was passed through the anastomotic site after the first operation; however, both the dilatation and dysmotility in the proximal segment continued. Interstitial cells of Cajal and smooth muscle cells are closely related to intestinal motility, as are neuronal cells (10). ICCs produce intestinal spontaneous construction, namely slow waves, as a pacemaker. Structurally, ICCs form gap junctions to both smooth muscle cells and each other, and they also are closely approached by nerve fiber varicosities containing synaptic vesicles (11). Therefore, ICCs are thought to be principal targets of both excitatory and inhibitory motor neurons that control intestinal motility (12). In addition, Won et al (13) showed that the dysmotility of the proximal segment was related to both muscularis inflammation and the disruption of the ICC network in an experimental obstruction rat model, using functional and morphological studies, as shown in our case. Therefore, the possible cause of the change in this case was the continuing proximal pressure load and secondary intramural inflammation with inadequate anastomosis leading to a continuation of the dilatation, thus resulting in both a decrease in the number of ICCs and the hypertrophy of the muscular layers. Both the smooth muscle cells and ICCs originated from mesenchymal cells (10). In general, both of these cell types are thought to be able to degenerate to the precursor and increase with changes in intramural circumstances (12). Nevertheless, in this case, both the distribution of ICCs and the muscular layer remained unchanged. Therefore, the long-term continuing high pressure load may lead to an irreversible change in the muscular layers and a disturbance in the improvement in the distribution of ICCs, as well as in the pressure load of the heart. In addition, an alteration of both the muscular layers and the ICCs themselves also may lead to a deterioration of motility in the proximal segment. Regarding the neuronal components, the decrease in the number of both neuronal cells and fibers improved at the second operation, despite the continuing proximal dilatation. Therefore, the decrease in both the number of neuronal cells and the fiber distribution at birth in the JA may be associated with a delay in the neuronal development in the proximal segment, secondary to the proximal dilatation due to the pressure load during the fetal period. In addition, the neuronal cells are reported to possibly be able to regenerate in the brain (14). If a similar regeneration of the intramural neurons occurs, then the intramural neuronal cells also may develop a wide distribution after birth, as shown in our case. At least there was a possibility that the neuronal improvement occurred even after the primary operation in the proximal segment of JA. However, even if the neuronal distribution improved, the intestinal motility may not sufficiently improve because of impairment in the signaling of the network of ICCs, as described above. Based on our findings, the continuation of severe dilatation in the proximal segment was thought to have induced a secondary negative effect on both the ICCs and the muscular layer, if an adequate resection of the proximal segment in JA had not been performed. The alteration in both the ICCs and the muscular layers due to the long-term severe dilatation may also have caused deterioration in the disturbed motility. Acknowledgment We would like to thank Mr Brian Quinn for reviewing the English in this manuscript." @default.
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• W2014768996 title "Chronological Change in Intramural Components in Severe Proximally Dilated Jejunal Atresia: An Immunohistochemical Study" @default.
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