Characterization of the Transition Zone in Short Segment Hirschsprung Disease Using Calretinin Immunostaining

Introduction: The detailed expression pattern of calretinin immunohistochemistry in the transition zone (TZ) of Hirschsprung disease (HSCR) has not yet been reported. This study aims to examine the value of calretinin immunohistochemistry for more accurately determining the distal and proximal border of the TZ in short segment HSCR. Methods: Specimens of pull-through surgery from 51 patients with short form of HSCR were analyzed on two longitudinal strips using hematoxylin and eosin (H&E) staining and calretinin immunohistochemistry. Results: In all but two patients, the first appearance of calretinin expression was seen on mucosal nerve fibers before the appearance of any ganglion cells, indicating the distal border of the TZ. The maximum distance between the distal border of the TZ and the proximal border of the TZ, defined by ganglion cells in a normal density on H&E stained sections, a strong calretinin expression on mucosal nerve fibers and in >80% of submucosal and myenteric ganglion cells, with no nerve hypertrophy and absence of ganglionitis was 60 mm. Conclusion: The distal border of the TZ is characterized by calretinin positive intramucosal neurites in nearly all of short form of HSCR and not by calretinin expression on ganglion cells.

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Total Colonic Aganglionosis: Case Report, Practical Diagnostic Approach and Pitfalls

Archives of Pathology & Laboratory Medicine ◽

10.5858/2010-0279-cr.1 ◽

2010 ◽

Vol 134 (10) ◽

pp. 1467-1473 ◽

Cited By ~ 3

Author(s):

Raja Rabah

Keyword(s):

Transition Zone ◽

Ganglion Cells ◽

Hirschsprung Disease ◽

Rectal Biopsy ◽

Nerve Fibers ◽

Submucosal Plexus ◽

Total Colonic Aganglionosis ◽

Biopsy Specimens ◽

Suction Rectal Biopsy ◽

Acetylcholinesterase Staining

Abstract Hirschsprung disease remains a challenging diagnosis for many pathologists. The disease is characterized by a lack of ganglion cells in the myenteric and submucosal plexus, associated with increased numbers of acetylcholinesterase-positive nerve fibers. Hypertrophic nerve fibers are present in most but not all patients. Total colonic aganglionosis (TCA) is an uncommon form of Hirschsprung disease with clinical, histologic, and genetic differences and is even more difficult to diagnose and manage. This case illustrates some of the difficulties frequently faced by the pathologists dealing with total colonic aganglionosis. Suction rectal biopsy specimens often lack significant nerve hypertrophy and positive acetylcholinesterase staining, which aid in the diagnosis. Pathologists have to depend mainly on the lack of ganglion cells in adequate submucosa to establish the diagnosis. Transition zone is often long in total colonic aganglionosis and interpretation of frozen sections can be difficult. The presence of several uniformly distributed clusters of mature ganglion cells and lack of nerve hypertrophy are required to avoid connections at the transition zone.

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Circumferential Distribution of Ganglion Cells in the Transition Zone of Children with Hirschsprung Disease

Pediatric and Developmental Pathology ◽

10.1007/s100249910028 ◽

2000 ◽

Vol 3 (3) ◽

pp. 216-222 ◽

Cited By ~ 58

Author(s):

Frances V. White ◽

Jacob C. Langer

Keyword(s):

Transition Zone ◽

Myenteric Plexus ◽

Ganglion Cells ◽

Hirschsprung Disease ◽

Leading Edge ◽

Marked Contrast ◽

Surgical Specimen ◽

Study Population ◽

Circumferential Distribution ◽

Pull Through

We prospectively studied the circumferential distribution of ganglion cells in the transition zone from a study population of 21 patients with Hirschsprung disease (HD) undergoing a pull-through procedure over a 26-month period. Twelve cases were satisfactory for examination, in that the transition zone was contained within a single surgical specimen and specimen distortion was minimal. Ganglion cells in the submucosa were counted in all 12 cases. In seven of the cases, the transition zone was proximal to the rectal sleeve and myenteric plexus ganglion cells were also counted. We found an uneven circumferential distribution of ganglion cells in both myenteric plexus and submucosa of the transition zone, resulting in a “leading edge” of ganglion cells extending into aganglionic distal bowel. The maximum length of this leading edge was 2.4 cm and 2.1 cm in the myenteric plexus and submucosa, respectively. Ganglion cells at the tip of the leading edge were present in clusters of up to six ganglion cells, in marked contrast to an absence of ganglion cells for most of the remainder of the circumference. Closely spaced myenteric plexus ganglia were seen at the tip of the leading edge in some cases. The leading edge was more frequently observed along the antimesenteric side, but this was not statistically significant. Our findings have relevance in the interpretation of intraoperative biopsies at the time of pull-through surgery and subsequent biopsies of neorectum in patients with surgically corrected HD.

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Image Processing and Analysis of Mucosal Calretinin Staining to Define the Transition Zone in Hirschsprung Disease: A Pilot Study

European Journal of Pediatric Surgery ◽

10.1055/s-0037-1618594 ◽

2018 ◽

Vol 29 (02) ◽

pp. 179-187 ◽

Cited By ~ 2

Author(s):

Saleh Najjar ◽

Sangtae Ahn ◽

Israel Kasago ◽

Chunlai Zuo ◽

Kavita Umrau ◽

...

Keyword(s):

Image Processing ◽

Transition Zone ◽

Hirschsprung Disease ◽

Continuous Variable ◽

Nerve Fibers ◽

Image Processing And Analysis ◽

Visual Scoring ◽

The Mean ◽

Pull Through ◽

Proximal Resection Margin

Purpose Quantification of calretinin-stained mucosal nerve fibers by image processing and analysis (IPA) may objectively define the transition zone (TZ) of Hirschsprung disease (HD). We tested the utility of IPA as an adjunctive tool in HD. Materials and Methods Calretinin immunostain was performed on 15 HD pull-through specimens, and multiple images were captured from the proximal aganglionic zone, TZ, and probable normal zone (NZ). Pixel count (PC), defined as the percentage of brown-stained pixels in the mucosa, was quantified and plotted against distance from the rectal distal end. To validate the method, PCs from 45 images were compared with three-tiered visual scoring by five pathologists. Results were correlated against pertinent variables, which were retrieved from the clinical record. Results The PC gradually increased in the TZ toward the proximal resection margin in 10/13 (77%) cases. The PC variation in the probable NZ and around the circumference was substantial by the coefficient of variation. The mean PC of images with a visual score of 1 was less than scores of 2 and 3 by all five (100%) pathologists (p < 0.01). One patient had possible TZ pull-through that was clinically confirmed. Conclusion While the mucosal calretinin staining gradually increases in the TZ, for now, the boundaries of the TZ cannot be accurately defined by mucosal biopsies given the substantial variation of staining around the circumference at the same distance and in the NZ. However, the IPA technique does provide a continuous variable and warrants further utility in HD studies.

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Reoperation for Hirschsprung Disease: Pathology of the Resected Problematic Distal Pull-Through

Pediatric and Developmental Pathology ◽

10.2350/11-02-0977-oa.1 ◽

2012 ◽

Vol 15 (1) ◽

pp. 30-38 ◽

Cited By ~ 38

Author(s):

Alexander Coe ◽

Margaret H. Collins ◽

Taiwo Lawal ◽

Emily Louden ◽

Marc A. Levitt ◽

...

Keyword(s):

Transition Zone ◽

High Power ◽

Ganglion Cells ◽

Frozen Section ◽

Hirschsprung Disease ◽

Postoperative Outcome ◽

Surgical Removal ◽

High Power Field ◽

Pull Through ◽

Poor Outcomes

Hirschsprung disease, which consists of aganglionosis of the rectum and sometimes more proximal bowel, requires surgical removal of the aganglionic bowel and creation of ganglionated neorectum using proximal normally innervated bowel. The border between aganglionic and ganglionic bowel is irregular; the transition zone features variable quantities of ganglion cells and numerous large nerves. We report the histopathology of pull-through bowel segments resected because of poor postoperative outcome from 30 patients (22 boys, 8 girls). The most common indication for reoperation was severe constipation/obstruction. Transition zone (bowel with at least two nerves ≥40 μm diameter per 400× high-power field, and ganglion cells) or aganglionic bowel (bowel with at least two nerves ≥40 μm per high-power field diameter, but without ganglion cells) was found in 19/30 (63%) resections. In colons resected because of familial adenomatous polyposis, rare high-power fields showed two enlarged nerves; the mean age of those patients (135 ± 49.4 months) was significantly higher than that of the patients undergoing redo pull-through surgery (67.9 ± 42.8 months). Additional pathology included stricture and enterocolitis. Although there are multiple causes for poor outcomes following surgical therapy for Hirschsprung disease, abnormal innervation of the bowel used for pull-through is common. We recommend that intraoperative consultation at primary pull-through procedure include frozen section evaluation of the circumference of the bowel to be used for pull-through to confirm histologically the presence of both ganglion cells and normal-caliber nerves. The criteria used in this study are most suitable for infants and young children.

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Are We Underdiagnosing Hirschsprung Disease?

Pediatric and Developmental Pathology ◽

10.1177/1093526619889434 ◽

2019 ◽

Vol 23 (1) ◽

pp. 60-71

Author(s):

Raj P Kapur ◽

Lusine Ambartsumyan ◽

Caitlin Smith

Keyword(s):

Transition Zone ◽

Ganglion Cells ◽

Hirschsprung Disease ◽

Rectal Biopsy ◽

Cholinergic Innervation ◽

Short Segment ◽

Recent Improvement ◽

Recent Trends ◽

Mucosal Innervation ◽

Rectal Biopsies

Hirschsprung disease (HSCR) is conventionally defined as aganglionosis of the distal rectum and a variable length of proximal contiguous bowel with a transition zone of ganglionic, but neuroanatomically abnormal, bowel located immediately upstream. Recent improvement in our understanding of the pathology and genetics of HSCR and relevant animal models indicates highly variable expressivity. The spectrum of intestinal neuropathology includes patients with very short-segment aganglionosis, limited to the distal 1 to 2 cm of the rectum, and possibly patients with no true aganglionic segment, but nonphysiological transition zone pathology in their distal rectums. The presence or absence of submucosal ganglion cells in a rectal biopsy is not sufficient to exclude these patients, in whom submucosal nerve hypertrophy and/or abnormal cholinergic mucosal innervation may be the only diagnostic clues. In addition, diagnosis or exclusion of HSCR by rectal biopsy now relies in part on mucosal patterns of calretinin immunohistochemistry, with less emphasis on submucosal tissue adequacy and assessment of cholinergic innervation. These recent trends in the surgical pathology approach to rectal biopsies may miss patients at the phenotypically milder end of the malformation spectrum, with profound implications for subsequent management, prognosis, and genetic counseling.

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

BMC Gastroenterology ◽

10.1186/s12876-021-01668-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Gunadi ◽

Gabriele Ivana ◽

Desyifa Annisa Mursalin ◽

Ririd Tri Pitaka ◽

Muhammad Wildan Zain ◽

...

Keyword(s):

Functional Outcomes ◽

Hirschsprung Disease ◽

Treatment Method ◽

Strongly Correlated ◽

Short Segment ◽

Multicenter Studies ◽

Operative Complications ◽

Pull Through ◽

Larger Sample ◽

Post Operative Complications

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

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Comparison of Hirschsprung Disease Characteristics between Those with a History of Postoperative Enterocolitis and Those without: Results from the Pediatric Colorectal and Pelvic Learning Consortium

European Journal of Pediatric Surgery ◽

10.1055/s-0040-1716876 ◽

2020 ◽

Author(s):

Mark A. Taylor ◽

Brian T. Bucher ◽

Ron W. Reeder ◽

Jeffrey R. Avansino ◽

Megan Durham ◽

...

Keyword(s):

Risk Factors ◽

Transition Zone ◽

Private Insurance ◽

Univariate Analysis ◽

Hirschsprung Disease ◽

Clinical Information ◽

Retrospective Case ◽

Disease Characteristics ◽

History Of ◽

Pull Through

Abstract Introduction The current understanding of Hirschsprung-associated enterocolitis (HAEC) is based mainly on single-center, retrospective studies. The aims of this study are to determine risk factors for postoperative HAEC using the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) database. Materials and Methods We performed a multicenter, retrospective, case–control study of children with Hirschsprung disease (HD) who had undergone a pull-through procedure and were evaluated at a PCPLC member site between February 2017 and March 2020. The cohort with a history of postoperative HAEC was compared with that without postoperative episodes of HAEC to determine relevant associations with postoperative HAEC. Results One-hundred forty of 299 (46.8%) patients enrolled had a history of postoperative HAEC. Patients with a rectosigmoid transition zone had a lower association with postoperative HAEC as compared with those with a more proximal transition zone (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.26, 0.84, p < 0.01). Private insurance was protective against postoperative HAEC on univariate analysis (OR: 0.62, 95% CI: 0.38, 0.99, p = 0.047), but not on multivariate analysis (OR: 0.62, 95% CI: 0.37, 1.04, p = 0.07). Preoperative HAEC was not associated with the development of postoperative HAEC. Conclusion Patients with a rectosigmoid transition zone have less postoperative HAEC compared with patients with a more proximal transition zone. Multi-institutional collection of clinical information in patients with HD may allow for the identification of additional risk factors for HAEC and afford the opportunity to improve care.

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Transanal-only Swenson-like pull-through for late diagnosed Hirschsprung disease

Journal of Surgical Case Reports ◽

10.1093/jscr/rjz341 ◽

2019 ◽

Vol 2019 (12) ◽

Cited By ~ 1

Author(s):

Rebecca M Rentea ◽

Devin R Halleran ◽

Hira Ahmad ◽

Elias Maloof ◽

Richard J Wood ◽

...

Keyword(s):

Transition Zone ◽

Prone Position ◽

Surgical Approach ◽

Patient Population ◽

Neonatal Period ◽

Hirschsprung Disease ◽

Small Subset ◽

Newborn Period ◽

Transanal Approach ◽

Pull Through

Abstract Hirschsprung disease (HD) is an obstructive colonic process usually diagnosed in the neonatal period. A small subset of cases are diagnosed late, present with severe constipation without enterocolitis and have low rectosigmoid disease. A transanal-only pull-through is a well-described approach but in the newborn period risks a situation whereby the transition zone is higher than the sigmoid. We present our experience with the unique patient population of older HD patients in whom the transition zone was reliably reachable via a single-stage transanal approach, performed in prone position. Patients between 2 and 6 years of age with a rectal or sigmoid transition zone and minimal proximal colonic dilation can undergo a primary transanal pull-through surgical approach.

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Safety and Accuracy of Suction Rectal Biopsy in Preterm Infants

Frontiers in Pediatrics ◽

10.3389/fped.2021.642342 ◽

2021 ◽

Vol 9 ◽

Author(s):

Yanan Zhang ◽

Yongwei Chen ◽

Shen Yang ◽

Yichao Gu ◽

Kaiyun Hua ◽

...

Keyword(s):

Preterm Infants ◽

Gestational Age ◽

Clinical Characteristics ◽

Ganglion Cells ◽

Hirschsprung Disease ◽

Rectal Biopsy ◽

Late Preterm Infants ◽

Suction Rectal Biopsy ◽

Pull Through

Purpose: Most pediatric surgeons give little attention to the diagnosis of Hirschsprung disease (HD) in preterm infants. We aimed to explore the safety and accuracy of suction rectal biopsy (SRB) for diagnosing HD in preterm infants.Methods: A retrospective review was conducted of 45 preterm patients who underwent SRB from 2015 to 2019 in our hospital. We collected the clinical characteristics and pathology results of the patients and information on follow-up. The sensitivity and specificity of SRB for HD diagnosis were calculated.Results: The median gestational age of the patients was 35 weeks (range: 28.9–36.9 weeks), the median gestational age at biopsy was 38.6 weeks (range: 33.4–60.0 weeks), and the median weight was 2,790 g (range: 1,580–4,100 g). Fifteen patients (33.3%) were positive for HD, which was confirmed after pull-through surgery. Ganglion cells were present in 30 patients. The diagnosis of HD was excluded in 29 patients after discharge follow-up. The sensitivity of SRB ranged from 93.7 to 100%, and the specificity was 100%. No complications occurred after SRB among the patients whose biopsy age was <37 weeks (10 patients) or biopsy weight was <2,000 g (five patients).Conclusion: SRB is accurate and safe for diagnosing HD in late preterm infants.

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Histochemical Diagnosis of Hirschsprung Disease

PEDIATRICS ◽

10.1542/peds.69.6.755 ◽

1982 ◽

Vol 69 (6) ◽

pp. 755-761

Author(s):

Carolyn Coker Huntley ◽

Louis deS. Shaffner ◽

Venkata R. Challa ◽

Anne D. Lyerly

Keyword(s):

Lamina Propria ◽

False Positive ◽

Ganglion Cells ◽

False Negative ◽

Hirschsprung Disease ◽

Nerve Fibers ◽

Infants And Children ◽

Muscularis Mucosa ◽

False Positive Reactions ◽

In Infants And Children

A histochemical staining technique for detection of acetylcholinesterase (AChE) in rectal suction biopsies was compared with the presence or absence of ganglion cells in full-thickness or suction biopsies for the diagnosis of Hirschsprung disease (HD) in infants and children. Biopsies from 55 of 58 children were adequate for both the AChE assay and routine pathologic examination for ganglion cells. Two patterns of AChE staining were noted. With pattern A, prominent nerve fibers staining for AChE were seen throughout the muscularis mucosa and the lamina propria. With pattern B, similar fibers were seen only in the muscularis mucosa and the areas of lamina propria that were immediately adjacent. No "false-negative" AChE staining reactions were found in patients with HD. No "false-positive" reactions showing pattern A were found. This pattern was diagnostic for HD. Three false-positive reactions were found showing pattern B in patients with conditions other than HD. Among 22 patients with HD, 19 were males and three were females. Pattern A occurred in all age groups and in both sexes. Pattern B in patients with HD was seen exclusively in male infants 1 month of age or less. Experience suggests that the AChE staining of rectal suction biopsies is an excellent screening test for HD in infants and children. If pattern B is encountered, however, the specimen should be examined by routine pathologic techniques for the presence of submucosal ganglion cells.

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