Hirschsprung disease

Diagnosing Hirschsprung disease by detecting intestinal ganglion cells using label-free hyperspectral microscopy

Hirschsprung disease (HD) is a congenital disorder in the distal colon that is characterized by the absence of nerve ganglion cells in the diseased tissue. The primary treatment for HD is surgical intervention with resection of the aganglionic bowel. The accurate identification of the aganglionic segment depends on the histologic evaluation of multiple biopsies to determine the absence of ganglion cells in the tissue, which can be a time-consuming procedure. We investigate the feasibility of using a combination of label-free optical modalities, second harmonic generation (SHG); two-photon excitation autofluorescence (2PAF); and Raman spectroscopy (RS), to accurately locate and identify ganglion cells in murine intestinal tissue without the use of exogenous labels or dyes. We show that the image contrast provided by SHG and 2PAF signals allows for the visualization of the overall tissue morphology and localization of regions that may contain ganglion cells, while RS provides detailed multiplexed molecular information that can be used to accurately identify specific ganglion cells. Support vector machine, principal component analysis and linear discriminant analysis classification models were applied to the hyperspectral Raman data and showed that ganglion cells can be identified with a classification accuracy higher than 95%. Our findings suggest that a near real-time intraoperative histology method can be developed using these three optical modalities together that can aid pathologists and surgeons in rapid, accurate identification of ganglion cells to guide surgical decisions with minimal human intervention.

How the Management of Children With Congenital Central Hypoventilation Syndrome Has Changed Over Time: Two Decades of Experience From an Italian Center

Background: Congenital central hypoventilation syndrome (CCHS) is a rare disorder whose clinical phenotype is closely related to genotype. Methods: A retrospective analysis has been conducted on 22 patients with CCHS, who were referred to the Pediatric Pulmonology and Respiratory Intermediate Care Unit of Bambino Gesù Children's Hospital (Italy) for a multidisciplinary follow-up program between 2000 and 2020. Results: Apnea and cyanosis were the most frequent symptoms at onset (91%). Overall, 59% of patients required tracheostomy and invasive mechanical ventilation (IMV) in the first months of life. Thirty-two percent of patients had Hirschsprung disease (HSCR) that was associated with longer polyalanine repetitions or non-polyalanine repeat expansion mutations (NPARMs). Polyalanine repeat expansion mutations (PARMs) were more frequent and two novel NPARMs (c.780dupT and C.225-256delCT) were described in 14% of patients. Focal epilepsy was first described in 14% of patients and neurocognitive and neuromotor impairment involved 27% and 23% of children, respectively. Symptoms due to autonomic nervous system dysfunction/dysregulation (ANSD)-including strabismus (27%), dysphagia (27%), abnormal heart rhythm (10%), breath-holding spells (9%), and recurrent seizures due to hypoglycemia (9%)-were associated with an increased number of polyalanine repetitions of exon 3 or NPARMs of PHOX2B gene. Overall, the number of patients with moderate to severe phenotype initially treated with non-invasive ventilation (NIV) increased over time, and the decannulation program was concluded with 3 patients who started with IMV. Conclusions: Our study confirms that more severe phenotypes of CCHS are related to the number of polyalanine repetitions or to NPARMs. Although invasive ventilation is often required by patients with severe genotype/phenotype, gradual acquisition of specific skills in the management of patients with CCHS and technological improvements in mechanical ventilation allowed us to improve our therapeutic approach in this population.

Surgical Correction of Hirschsprung's Disease in Children Using the Soave-Boley Technique with Manual Colorectal Anastomosis

Introduction. Current trends in surgical treatment of Hirschsprung's disease are aimed at minimally invasive interventions. However, the experience of using Soave-Boley procedure in surgical treatment of Hirschsprung's disease in children of different ages is valuable in the arsenal of differentiated approach to the treatment of this pathology. The objective of the research was to evaluate the results of surgical correction of Hirschsprung's disease in children using the Soave-Boley technique with manual colorectal anastomosis. Materials and Methods. The analysis of surgical treatment of 1,187 children with different forms of Hirschsprung’s disease aged from birth to 18 years over the period 1980-2020 was conducted in the National Children's Specialized Hospital“ Okhmatdyt”. Surgical correction of Hirschsprung's disease using the Soave-Boley technique was performed in 597 children. Before surgery, 156 patients underwent the first stage of treatment that consisted in the creation of a protective colostomy; in 441 cases, this intervention was performed without an intestinal stoma; the benefits of the Soave-Boley technique were evaluated. Results. All the patients survived. In 15 (2.51%) out of 597 children, in the early postoperative period, there were observed: retrocolic hematoma (n = 2), retrocolic abscess (n = 7), anastomotic leak (n = 2), adhesive intestinal obstruction (n = 3), intussusception (n = 1). Fourteen (2.36%) patients developed surgical complications in the long-term period: residual aganglionosis (n = 9), anastomotic stenosis (n = 4) and coloptosis. Repeated Soave-Boley operation with manual colorectal anastomosis was successfully performed in 26 (4.362%) patients after primary correction of Hirschsprung's disease using different methods. Periodic episodes of fecal smearing in the remote period in 45 (7.53%) children were eliminated by conservative treatment. The success of this technique is confirmed by a much lower number of early (2.51%) and late (2.36%) postoperative surgical complications, as compared to those after using other methods of open surgical correction - 17.52% and 16.35%, respectively. Conclusions. Surgical correction of Hirschsprung's disease in children using the Soave-Boley technique with manual colorectal anastomosis allows better control over applying each suture, anatomical joining the edges of the bowel, and reducing trauma to the rectal mucosa, which ensures the high reliability of colorectal anastomosis; it is the most effective way of radical correcting Hirschsprung' s disease in children in an open way in one-stage or two-stage interventions, and this technique is the operation of choice for secondary surgical correction of Hirschsprung's disease.

Analysis of enteric nervous system and intestinal epithelial barrier to predict complications in Hirschsprung's disease

In Hirschsprung’s disease (HSCR), postoperative course remains unpredictable. Our aim was to define predictive factors of the main postoperative complications: obstructive symptoms (OS) and Hirschsprung-associated enterocolitis (HAEC). In this prospective multicentre cohort study, samples of resected bowel were collected at time of surgery in 18 neonates with short-segment HSCR in tertiary care hospitals. OS and HAEC were noted during postoperative follow-up. We assessed the enteric nervous system and the intestinal epithelial barrier (IEB) in ganglionic segments by combining immunohistochemical, proteomic and transcriptomic approaches, with functional ex vivo analysis of motility and para/transcellular permeability. Ten HSCR patients presented postoperative complications (median follow-up 23.5 months): 6 OS, 4 HAEC (2 with OS), 2 diarrhoea (without OS/HAEC). Immunohistochemical analysis showed a significant 41% and 60% decrease in median number of nNOS-IR myenteric neurons per ganglion in HSCR with OS as compared to HSCR with HAEC/diarrhoea (without OS) and HSCR without complications (p = 0.0095; p = 0.002, respectively). Paracellular and transcellular permeability was significantly increased in HSCR with HAEC as compared to HSCR with OS/diarrhoea without HAEC (p = 0.016; p = 0.009) and HSCR without complications (p = 0.029; p = 0.017). This pilot study supports the hypothesis that modulating neuronal phenotype and enhancing IEB permeability may treat or prevent postoperative complications in HSCR.

Importance of education and the role of the patient and family in the care of anorectal malformations

During this early part of the 21st century online technology has prompted many major advances in medical care. In this section we argue that this is particularly evident in the treatment and care of patients born with Anorectal Malformation (ARM) and Hirschsprung's Disease (HD). Our stories show that anyone born with these complex colorectal conditions in the 20th century was destined to a life of isolation and stigma. Here we explore the lack of understanding and recognition of the psychological effects on children and families which has characterised this period. We show that advances in clinical practice has been supported by developing social media platforms. There has been a rapid creation of online support groups for patients and families which has enabled survivors' greater access to patient and parent organizations across the globe and thereby stimulated a sense of belonging and solidarity. Online technology and social media platforms have also opened up the opportunity for pediatric medical professionals to provide a greater level of patient education. There is no doubt families have become much more aware of the complexities of ARM & HD and achieved greater comfort and understanding of their needs. We have generated "lightbulb moments" for pediatric providers with adult ARM & HD patients, enabling them to share their lived experiences in a therapeutic exchange. In the past survivors felt they were abandoned by the adult healthcare system. We are seeing evidence-based research of major psychosocial issues experienced by adult patients and, as a result, improved understanding of how to treat ARM & HD survivors across their whole of life journey. The winds of change continue to direct our cohorts to a mature approach based on improving levels of interactive communication and education. We argue that this maturity has mostly been facilitated by the use of online technology and the ensuing collaboration between providers and patient and parent organizations.

Intestinal proinflammatory macrophages induce a phenotypic switch in interstitial cells of Cajal

Interstitial cells of Cajal (ICCs) are pacemaker cells in the intestine, and their function can be compromised by loss of C-KIT expression. Macrophage activation has been identified in intestine affected by Hirschsprung disease-associated enterocolitis (HAEC). In this study, we examined proinflammatory macrophage activation and explored the mechanisms by which it downregulates C-KIT expression in ICCs in colon affected by HAEC. We found that macrophage activation and TNF-α production were dramatically increased in the proximal dilated colon of HAEC patients and 3-week-old Ednrb-/- mice. Moreover, ICCs lost their C-KIT+ phenotype in the dilated colon, resulting in damaged pacemaker function and intestinal dysmotility. However, macrophage depletion or TNF-α neutralization led to recovery of ICC phenotype and restored their pacemaker function. In isolated ICCs, TNF-α-mediated phosphorylation of p65 induced overexpression of microRNA-221 (miR-221), resulting in suppression of C-KIT expression and pacemaker currents. We also identified a TNF-α/NF-κB/miR-221 pathway that downregulated C-KIT expression in ICCs in the colon affected by HAEC. These findings suggest the important roles of proinflammatory macrophage activation in a phenotypic switch of ICCs, representing a promising therapeutic target for HAEC.

The Enteric Nervous System and Its Emerging Role as a Therapeutic Target

The gastrointestinal (GI) tract is innervated by the enteric nervous system (ENS), an extensive neuronal network that traverses along its walls. Due to local reflex circuits, the ENS is capable of functioning with and without input from the central nervous system. The functions of the ENS range from the propulsion of food to nutrient handling, blood flow regulation, and immunological defense. Records of it first being studied emerged in the early 19th century when the submucosal and myenteric plexuses were discovered. This was followed by extensive research and further delineation of its development, anatomy, and function during the next two centuries. The morbidity and mortality associated with the underdevelopment, infection, or inflammation of the ENS highlight its importance and the need for us to completely understand its normal function. This review will provide a general overview of the ENS to date and connect specific GI diseases including short bowel syndrome with neuronal pathophysiology and current therapies. Exciting opportunities in which the ENS could be used as a therapeutic target for common GI diseases will also be highlighted, as the further unlocking of such mechanisms could open the door to more therapy-related advances and ultimately change our treatment approach.

Long-term outcomes of laparoscope-assisted heart-shaped anastomosis for children with hirschsprung disease: A 10-year review study

BACKGROUND AND OBJECTIVE

Several operating procedures have been reported for treating Hirschsprung Disease (HD), but the incidence of postoperative complications remains at a high level affecting both the patients' prognosis and postoperative life quality. Heart-shaped anastomosis as a novel surgery method for children with HD has been improved by our medical center. This new surgery method is characterized by a heart-shaped colorectal anastomosis after splitting the posterior rectum wall to 0.5 cm above the dentate line. The aim of this review was to research the outcomes and quality of life of laparoscope-assisted heart-shaped anastomosis (LHSA) for children with HD by comparing it with a more generally applied surgery method, the laparoscope-assisted Soave procedure (LSP).

METHODS

A retrospective review was conducted for 198 patients who underwent operations from January 2005 to December 2014 in our institution, who were divided into 97 cases of the LHSA group and 101 cases of LSP group according to the treatment methods; all the outcomes and individual quality of life data were assessed and compared.

RESULT

All the enrolled 198 children diagnosed with HD, LHSA and LSP had been successfully completed in all cases. For complications, the incidence of constipation and soiling in the LHSA group was lower than the LSP group (P = 0.030, P = 0.042 respectively). On aspects of quality of life after operation, the individual quality of life of children with fecal incontinence was scored; and the higher the scores, the better the quality of life. Patients in the LHSA group had higher scores in terms of soiling, unhappy or anxious and peer rejection than the LSP group (P = 0.003, P = 0.009, P = 0.021, respectively). Other surgical characteristics and outcomes did not significantly differ between the two groups.

CONCLUSION

LHSA is a feasible and safe minimally invasive surgery method with good long-term follow-up outcomes for HD patients. Compared with LSP, LHSA has advantages of low incidence of constipation and soiling, and provides better quality of life. Therefore, LHSA may provide a better choice for HD patients.

LEVELS OF EVIDENCE

The type of study was Clinical Research Paper and the level of evidence was level III.

Downregulation of miR-140-5p affects the pathogenesis of HSCR by targeting EGR2

BACKGROUND/AIMS

Hirschsprung's disease (HSCR) is the most common digestive disease caused by disorders of neural crest development. Despite the known involvement of miR-140-5p in many human diseases, its biological role in Hirschsprung's disease (HSCR) remains undefined. In this study, we sought to reveal the roles of miR-140-5p in the pathogenesis of HSCR.

METHODS

Quantitative real-time PCR and western blotting were used to measure the relative expression levels of miRNAs, mRNAs, and proteins in stenotic and dilated sections of the colon of 32 HSCR patients. Targets and proteins were evaluated by western blotting, and Transwell, CCK-8, and flow cytometry assays were adopted to detect the functional effects of miR-140-5p on SH-SY5Y cells.

RESULTS

miR-140-5p was significantly downregulated in HSCR tissue samples with increased expression of EGR2, and knockdown of miR-140-5p inhibited cell migration and proliferation and promoted apoptosis in SH-SY5Y cell lines. EGR2 expression was inversely correlated with that of miR-140-5p in cell lines.

CONCLUSIONS

miR-140-5p may influence the pathogenesis of HSCR by targeting EGR2.

ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease

BACKGROUND

Hirschsprung's disease (HSCR) is a serious congenital bowel disorder with a prevalence of 1/5000. Currently, there is a lack of systematically developed guidelines to assist clinical decision-making regarding diagnostics and management.

AIMS

This guideline aims to cover the diagnostics and management of rectosigmoid HSCR up to adulthood. It aims to describe the preferred approach of ERNICA, the European Reference Network for rare inherited and congenital digestive disorders.

METHODS

Recommendations within key topics covering the care pathway for rectosigmoid HSCR were developed by an international workgroup of experts from 8 European countries within ERNICA European Reference Network from the disciplines of surgery, medicine, histopathology, microbiology, genetics, and patient organization representatives. Recommendation statements were based on a comprehensive review of the available literature and expert consensus. AGREE II and GRADE approaches were used during development. Evidence levels and levels of agreement are noted.

RESULTS

Thirty-three statements within 9 key areas were generated. Most recommendations were based on expert opinion.

CONCLUSION

In rare or low-prevalence diseases such as HSCR, there remains limited availability of high-quality clinical evidence. Consensus-based guidelines for care are presented.

Long-term outcomes of single-incision laparoscopic technique in Soave procedure compared with heart-shaped anastomosis for Hirschsprung disease

PURPOSE

This retrospective study compared the long-term outcomes of single-incision laparoscopy-assisted Soave procedure (SILSP) with single-incision laparoscopy-assisted heart-shaped anastomosis (SILHSA) in patients with Hirschsprung disease (HSCR).

METHODS

Patients diagnosed with HSCR that underwent SILSP or SILHSA between January 2009 and January 2015 at our institute were enrolled in this retrospective study. Data on the clinical characteristics, perioperative complications, and postoperative quality of life were retrospectively collected and analyzed.

RESULTS

There were 109 patients in the SILSP group and 95 patients in the SILHSA group. No differences in clinical characteristics, including age, weight, hospitalization length, blood loss volume, and operation time, were noted between the two groups. The incidence rates of constipation and soiling were lower in the SILHSA group than those in the SILSP group. The SILHSA group showed lower scores in constipation and soiling compared with the SILSP group, indicating a better surgical outcome for patients receiving SILHSA procedure.

CONCLUSION

SILHSA is a feasible and reliable minimally invasive surgical procedure for patients with HSCR. Patients who underwent SILHSA had lower incidence rates of constipation and soiling than patients who underwent SILSP, suggesting that SILHSA could be a better choice for patients with HSCR.

Negative Association Between lncRNA HOTTIP rs3807598 C>G and Hirschsprung Disease

Background

Hirschsprung disease (HSCR) is a congenital disease that arises from defective intestinal neural system. LncRNA HOTTIP is a critical gene in various diseases, including HSCR. No epidemiological studies have explored the correlation between lncRNA HOTTIP single nucleotide polymorphisms (SNPs) and HSCR risk. We here lead as a pioneer to explore whether SNPs in lncRNA HOTTIP impact the risk of HSCR and HSCR subtypes in an unrelated Chinese population.

Methods

We used the TaqMan method to genotype rs3807598 C>G of the lncRNA HOTTIP gene using 1470 HSCR cases and 1473 healthy controls. Of them, 1441 cases and 1434 controls were successfully genotyped. We adopted odds ratios (ORs) and 95% confidence intervals (CIs) to quantify the relationship.

Results

We got an unexpected outcome that lncRNA HOTTIP SNP rs3807598 C>G could not modify the risk of HSCR (CG vs. CC: adjusted OR=0.89, 95% CI=0.74–1.07; GG vs. CC: adjusted OR=1.10, 95% CI=0.89–1.37; GG/CG vs CC: adjusted OR=0.95, 95% CI=0.80–1.13; and GG vs. CC/CG: adjusted OR=1.19, 95% CI=0.99–1.43). What’s more, risk effect of lncRNA HOTTIP rs3807598 C>G is still not obvious in stratification analysis by HSCR subtype.

Conclusion

Our studies did not provide statistical evidence of a correlation between lncRNA HOTTIP SNP rs3807598 C>G and susceptibility of HSCR in the Chinese population that is being studied. Further validation study with a larger sample size covering multi-ethnic groups is warranted.

Electroacupuncture to Increase Neuronal Stem Cell Growth

Background: Neuropathic intestinal disorders continue to pose a significant burden, and current treatment options do not target the underlying cellular deficiencies. The goal of this study is to determine whether acupuncture and electroacupuncture (EA) can affect the growth of neuronal cells. Methods: Three groups of Lewis rats received 25 minutes of acupuncture twice a week for 10 weeks. The 3 groups of rats received treatment with either sham acupuncture (SA), real acupuncture (RA), or EA. After 10 weeks of treatment, skin and intestinal tissue were collected and analyzed for histology and mRNA expression of neuronal marker genes. Results: Compared with rats that received SA, rats that received RA and EA showed a significant increase in the mRNA expression levels of multiple neuronal genes in the skin. No significant histologic changes were seen. Conclusions: Acupuncture and EA result in significant changes in the expression of genes implicated as markers for neural stem cells, neural cell development, and neurons. This may, therefore, provide a novel avenue for developing treatments in patients suffering from intestinal aganglionic and neuropathic diseases.

Intestinal organoids in infants and children

Recent advances in culturing of intestinal stem cells and pluripotent stem cells have led to the development of intestinal organoids. These are self-organizing 3D structures, which recapitulate the characteristics and physiological features of in vivo intestinal epithelium. Intestinal organoids have allowed the development of novel in vitro models to study various gastrointestinal diseases expanding our understanding of the pathophysiology of diseases and leading to the development of innovative therapies. This article aims to summarize the current usage of intestinal organoids as a model of gastrointestinal diseases and the potential applications of intestinal organoids in infants and children. Intestinal organoids allow the study of intestinal epithelium responses to stress factors. Mimicking intestinal injury such as necrotizing enterocolitis, intestinal organoids increases the expression of pro-inflammatory cytokine genes and shows disruption of tight junctions after they are injured by lipopolysaccharide and hypoxia. In cystic fibrosis, intestinal organoids derived from rectal biopsies have provided benefits in genetic studies and development of novel therapeutic gene modulation. Transplantation of intestinal organoids via enema has been shown to rescue damaged colonic epithelium in mice. In addition, tissue-engineered small intestine derived from intestinal organoids have been successfully established providing a potential novel treatment and a new hope for children with short bowel syndrome.

Diagnosis of Hirschsprung Disease

Diagnosis or exclusion of Hirschsprung disease (HSCR) is a frequent exercise in any pediatric hospital. Although HSCR may present at different ages and with varied clinical findings, the most common presentation is a neonate with severe constipation or signs of intestinal obstruction. A variety of diagnostic tests including contrast enema and anorectal manometry may be used as diagnostic screens, but diagnosis ultimately rests upon histopathological evaluation of a rectal biopsy. For the experienced pathologist, conventional hematoxylin-and-eosin-stained sections often suffice to exclude HSCR or establish the diagnosis. However, ancillary diagnostic tests such as acetylcholinesterase histochemistry or calretinin immunohistochemistry are complementary and extremely helpful in some cases. In this Perspectives article, we review the clinical and pathological features of HSCR, highlight those that are found in most patients, and discuss how to address particularly challenging aspects of the diagnostic workup.

Wnt Signaling in Neural Crest Ontogenesis and Oncogenesis

Neural crest (NC) cells are a temporary population of multipotent stem cells that generate a diverse array of cell types, including craniofacial bone and cartilage, smooth muscle cells, melanocytes, and peripheral neurons and glia during embryonic development. Defective neural crest development can cause severe and common structural birth defects, such as craniofacial anomalies and congenital heart disease. In the early vertebrate embryos, NC cells emerge from the dorsal edge of the neural tube during neurulation and then migrate extensively throughout the anterior-posterior body axis to generate numerous derivatives. Wnt signaling plays essential roles in embryonic development and cancer. This review summarizes current understanding of Wnt signaling in NC cell induction, delamination, migration, multipotency, and fate determination, as well as in NC-derived cancers.

"Too much guts and not enough brains": (epi)genetic mechanisms and future therapies of Hirschsprung disease - a review

Hirschsprung disease is a neurocristopathy, characterized by aganglionosis in the distal bowel. It is caused by failure of the enteric nervous system progenitors to migrate, proliferate, and differentiate in the gut. Development of an enteric nervous system is a tightly regulated process. Both the neural crest cells and the surrounding environment are regulated by different genes, signaling pathways, and morphogens. For this process to be successful, the timing of gene expression is crucial. Hence, alterations in expression of genes specific for the enteric nervous system may contribute to the pathogenesis of Hirschsprung’s disease. Several epigenetic mechanisms contribute to regulate gene expression, such as modifications of DNA and RNA, histone modifications, and microRNAs. Here, we review the current knowledge of epigenetic and epitranscriptomic regulation in the development of the enteric nervous system and its potential significance for the pathogenesis of Hirschsprung’s disease. We also discuss possible future therapies and how targeting epigenetic and epitranscriptomic mechanisms may open new avenues for novel treatment.

Enterocolitis in a Child With Hirschsprung Disease

Hirschsprung disease is a congenital abnormality that can be surgically corrected. However, Hirschsprung-associated enterocolitis can be a life-threatening sequela. Very little has been published in the emergency medicine literature about the risk of enterocolitis and shock in patients with a history of Hirschsprung disease. We describe the case of a 6-month-old male infant with a history of multiple surgeries for Hirschsprung disease who presented to the emergency department with a seemingly benign viral gastrointestinal illness. His stable condition led him to be discharged. However, 4 days later, he returned to the emergency department with severe diarrhea and was subsequently admitted to the pediatric intensive care unit for the management of enterocolitis and shock. With this case report, we aim to raise emergency physicians' awareness of the serious and possibly fatal complications of Hirschsprung disease. We argue that this single element of a patient's medical history can alter the management of seemingly simple viral gastrointestinal illnesses; rather than be discharged, such a patient requires surgical consultation and possibly admission for close monitoring and treatment.

Should we look for Hirschsprung disease in all children with meconium plug syndrome?

BACKGROUND

Meconium plug syndrome (MPS) is associated with Hirschsprung disease (HD) in 13-38% of cases. This study sought to assess institutional variation in utilization of rectal biopsy in children with MPS and the likelihood of diagnosing HD in this population.

METHODS

Patients with MPS on contrast enema in the first 30 days of life from the Pediatric Health Information System database in 2016-2017 were included. Institutional rates of rectal biopsies performed during the initial admission were calculated and then used to predict institutional rates of early HD diagnoses using Poisson regression.

RESULTS

Of 373 newborns with MPS, 106 (28.4%) underwent early rectal biopsy, of whom 43 (40.5%) had HD. Fifty-seven (15.3%) were ultimately diagnosed with HD. Eight (14%) of these patients had a delayed diagnosis. HD rates between institutions did not differ significantly (range 0-50%, p=0.52), but usage of early rectal biopsy did (range 0-80%, p=0.03). Each additional early biopsy increased the early HD diagnosis rate by 35% (β=0.30, 95% CI 0.15-0.45, p<0.0001).

CONCLUSION

The incidence of HD is increased in children with MPS. There is significant hospital variability in the utilization of early rectal biopsy, and opportunity exists to standardize practice.

TYPE OF STUDY

Study of Diagnostic test Level of Evidence: Level III.

Results of rectoanal manometry after a novel laparoscopic technique: laparoscope-assisted heart-shaped anastomosis for Hirschsprung's disease

PURPOSE

The present research utilizes a mid-term follow-up study to assess the results of anorectal manometry after laparoscope-assisted heart-shaped anastomosis (LHSA) for Hirschsprung's disease (HSCR), and compares it to a more generally applied approach, the laparoscope-assisted Soave procedure (LSP).

METHODS

Retrospectively, patients from January 2015 to June 2017 who received LHSA or LSP were included in this study. After surgery, anorectal manometry was performed by the outpatient department. Anal sphincter resting pressure, anal canal length, amplitude of anal contraction, and frequency of anal contraction pre- and postoperatively were recorded. Additionally, mid-term complications were also monitored.

RESULTS

Preoperative manometry showed no statistically significant difference between the LHSA and LSP groups. Postoperatively, anal sphincter resting pressure was lower in the LHSA group (60.64 ± 9.33 vs. 68.84 ± 11.80 mmHg, p = 0.001). Furthermore, anal canal length of the LHSA group was shorter than that of the LSP group (1.41 ± 0.18 vs. 1.53 ± 0.25 cm, p = 0.015). Frequency of anal contraction also showed a statistically significant difference between the LHSA and LSP groups (13.53 ± 2.17 vs. 12.50 ± 2.03 per minute, p = 0.032). The complication rates showed no significant difference and were as follows: incidence of enterocolitis was 13.89% in the LHSA group and 20.45% in the LSP group, incidence of constipation was 11.11% after LHSA and 27.27% after LSP, and incidence of soiling was 13.89% after LHSA and 25.00% after LSP.

CONCLUSIONS

Manometric results of this study show satisfactory outcomes after LHSA. LHSA is an advanced surgical technique to make intestinal anastomosis easy and ensure a good prognosis.

The relationship of eosinophilia with outcomes of Hirschsprung disease in children

PURPOSE

It has been postulated that children with Hirschsprung disease (HD) and mucosal eosinophilia have been thought to have poorer outcome, but supporting evidence is lacking. The objective of our study was to review the outcomes of children with HD and mucosal eosinophilia.

METHODS

A single center, retrospective review was conducted on all patients diagnosed with HD between 1999 and 2016. Pathology specimens were evaluated for mucosal eosinophilia. Demographics, complications, and outcomes were analyzed.

RESULTS

A total of 100 patients were diagnosed with HD and 27 had mucosal eosinophilia. Median age at the time of surgery was 12 days (8, 30) and 82 were males. Comparing patients with HD with and without mucosal eosinophilia, there was no statistically significant difference in time to bowel function (2 days vs. 2 days; p = 0.85), time to start feeds (3 days vs. 3 days; p = 0.78) and time to goal feeds (5 days vs. 5 days; p = 0.47). There was no statistically significant difference in feeding issues (13% vs. 9%; p = 1.0) and stooling issues (60% vs. 50%; p = 0.38). There was no statistically significant difference in postoperative complications and readmissions rates (63% vs. 56%; p = 0.53).

CONCLUSION

Hirschsprung-associated mucosal eosinophilia may not increase postoperative complications, and may not change feeding and bowel management. Further prospective studies are in process to evaluate long term follow-up outcomes for this patient population.

Optimal time for single-stage pull-through colectomy in infants with short-segment Hirschsprung disease

OBJECTIVE

Short-segment Hirschsprung disease (HSCR) is the predominant type of HSCR that affects approximately 75% of patients. Whether single-stage endorectal pull-through (ERPT) surgery is appropriate for neonatal patients with HSCR has not been definitively determined. This retrospective cohort study concerning infants with short-segment HSCR investigated the optimal age for single-stage ERPT surgery, regardless of the operative approach.

METHODS

The 198 patients were stratified by operative age ≤ 3 or > 3 months (groups A or B, respectively, n = 62 and 136, respectively). Diagnoses of short-segment HSCR were conducted by preoperative contrast enema and rectal suction biopsy with acetylcholinesterase immunohistochemical staining. The perioperative clinical course for all patients was reviewed and the accuracy rate of the preoperative diagnoses and postoperative short- and midterm outcomes were assessed.

RESULTS

The rates of diagnostic accuracy, according to the results of the preoperative contrast enema or rectal suction biopsy, were lower in group A (67.2 and 93.5%, respectively) than in group B (81.4 and 94.9%, respectively). In groups A and B, 49 (79.1%) and 108 (79.4%) infants, respectively, completed follow-up examinations. The short-term outcomes were postoperative HSCR-associated enterocolitis, adhesive bowel obstruction, anastomosis leakage, and anal stenosis during the first 12 months after surgery. The midterm outcomes were incontinence and constipation at ~24 months after surgery. Compared with group B, group A experienced more incidences of anastomotic leakage in the short-term and more soiling in the midterm. In groups A and B, the rates of constipation recurrence were nil and 1.9%, respectively.

CONCLUSION

Infants with HSCR ≤3 months old at the time of single-stage ERPT surgery showed lower rates of accurate and conclusive diagnostic results and poorer postoperative outcomes. Waiting to perform this surgery until infants are older might be more beneficial.

Increased miR-214 expression suppresses cell migration and proliferation in Hirschsprung disease by interacting with PLAGL2

BACKGROUND

The miR-214 has been reported to be associated with various diseases, but its involvement in the pathophysiology of Hirschsprung disease (HSCR) is almost completely unexplored.

METHODS

In our study, we conducted a series of experiments to unravel the biological role of miR-214 in the pathophysiology of HSCR. qRT-PCR and western blotting were utilized to investigate the relative expression levels of miR-214, mRNAs, and proteins of related genes in colon tissues from 20 controls without HSCR and 24 patients with HSCR. The potential biological role of miR-214 in two cell lines (SKN-SH and SH-SY5Y) was assessed using the CCK8 assay, EdU staining, transwell assay, and flow cytometry. The dual-luciferase reporter assay was used to confirm PLAGL2 as a common target gene of miR-214.

RESULTS

All results suggested that miR-214 is upregulated in HSCR tissue samples compared with controls. Additionally, we found that miR-214 could inhibit cell proliferation and migration by directly downregulating the expression of PLAGL2, and the extent of the miR-214-mediated inhibitory effects could be rescued by a PLAGL2 overexpression plasmid.

CONCLUSION

Our results revealed that miR-214 is indeed involved in the pathophysiology of HSCR and suppresses cell proliferation and migration by directly downregulating PLAGL2 in cell models.

Long non-coding RNA FAL1 functions as a ceRNA to antagonize the effect of miR-637 on the down-regulation of AKT1 in Hirschsprung's disease

OBJECTIVES

Emerged evidence demonstrates that long non-coding RNAs (lncRNAs) may play quintessential regulatory roles in the cellular processes, tumourigenesis and the development of disease. Though focally amplified lncRNA on chromosome 1 (FAL1) has been identified to have crucial functions in many diseases, its biological mechanism in the development of Hirschsprung's disease (HSCR) still remains unknown.

MATERIALS AND METHODS

The expression levels of FAL1 in HSCR aganglionic tissues and matched normal specimens were detected by quantitative real-time PCR (qRT-PCR). Cell proliferation and migration were detected by Cell Counting Kit-8 (CCK-8) assay, Ethynyl-deoxyuridine (EdU) assay and transwell assay relatively. Cell cycle and apoptosis were assessed using flow cytometer analysis. Moreover, the novel targets of FAL1 were confirmed with the help of bioinformatics analysis and dual-luciferase reporter assay. Western blot assay as well as RNA immunoprecipitation (RIP) assay was conducted to investigate the potential mechanism.

RESULTS

FAL1 expression was markedly down-regulated in HSCR aganglionic tissues and decreased FAL1 expression was associated with the diagnosis of HSCR. Cell functional analyses indicated that FAL1 overexpressing notably promoted cell proliferation and migration, while down-regulation of FAL1 suppressed cell proliferation and migration. Additionally, Flow cytometry assay demonstrated that knockdown of FAL1 induced markedly cell cycle stalled in the G0/G1 phase. Furthermore, FAL1 could positively regulate AKT1 expression by competitively binding to miR-637.

CONCLUSIONS

These results illuminated that FAL1 may work as a ceRNA to modulate AKT1 expression via competitively binding to miR-637 in HSCR, suggesting that it may be clinically valuable as a biomarker of HSCR.

Long-term outcome and quality of life in patients with total colonic aganglionosis in the Netherlands

AIM

Total colonic aganglionosis (TCA) is a severe form of Hirschsprung's disease (HD) associated with a high morbidity. This study assessed long-term functional outcome and quality of life (QoL) of patients with TCA in a national consecutive cohort.

METHODS

Surgical and demographic characteristics in the medical records of all patients (n = 53) diagnosed with TCA between 1995 and 2015 were reviewed. Functional outcome of all nonsyndromal patients, aged ≥ 4 years (n = 35), was assessed using a questionnaire and in medical records. Generic and disease-specific QoL were assessed using standardized validated questionnaires.

RESULTS

Of 35 patients eligible for follow-up, 18 (51%) responded to the questionnaires. They were aged 4-19 years. A Duhamel procedure was performed in 67% of these patients and a Rehbein procedure was performed in 33%. In the questionnaire, 65% of the patients reported constipation, 47% faecal incontinence and 53% soiling. Moreover, 18% of patients used bowel management (flushing or laxatives) and 29% had an adapted diet only. Children and adolescents with TCA had worse perception of their general health and were more limited by bodily pain and discomfort compared with healthy peers. Their quality of life is influenced most by frequent complaints of diarrhoea and other physical symptoms.

CONCLUSION

Children and adolescents with TCA report lower health-related QoL compared with healthy peers, especially in the physical domain. We suggest standardized follow-up and prospective longitudinal future research on functionality and QoL of these patients.

Predicting sexual problems in young adults with an anorectal malformation or Hirschsprung disease

AIM

The aim of this study was to examine the prevalence of sexual dysfunction and distress and to assess whether sexual functioning could be predicted by psychosocial factors in childhood and adolescence in patients with an anorectal malformation or Hirschsprung disease.

MATERIAL AND METHODS

In 1998 patients completed a psychosocial questionnaire: The Self-Perception profile. To assess the prevalence of sexual distress and sexual functioning in adulthood (2015) the Female Sexual Function Index (FSFI), The Female Sexual Distress Scale (FSDS) and the International Index of Erectile Functioning (IIEF) were used.

RESULTS

In total 74 patients returned the questionnaires (26.2%). 36.8% of women reported sexual dysfunction and 45% experienced sexual distress. In our male sample 8.8% reported mild to moderate erectile dysfunction. In females perceived self-competence in adolescence was associated with sexual distress (p<.01). In male adolescents associations were found between perceived self-competence in romantic relations (p<.01) and in close friendships (p<.05) and sexual desire in adulthood.

CONCLUSION

Pediatric surgeons should be more aware of sexual problems patients may face at older age as a result of their congenital disease and treatment. More standardized care and follow-up are needed. Prognosis study-Level II.

Identification of risk factors for postoperative recurrent Hirschsprung associated enterocolitis

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A Long-Term Follow-Up of a New Surgery Method: Laparoscope-Assisted Heart-Shaped Anastomosis for Hirschsprung's Disease

BACKGROUND

Laparoscopic surgery is widely used in the treatment of Hirschsprung's disease (HD). However, constipation and soiling are still the main long-term complications. A new type of anastomosis, which is characterized by a heart-shaped colorectal anastomosis after splitting the posterior rectum wall to 0.5 cm above the dentate line, has been improved by our medical center. The purpose of this study was to determine the long-term effects of laparoscope-assisted heart-shaped anastomosis (LHSA) and to compare it with a more generally applied approach, the laparoscope-assisted Soave procedure (LSP).

PATIENTS AND METHODS

In this retrospective study, we investigated the symptoms of chronic constipation and soiling in 56 patients after LHSA and 54 patients after LSP between 2005 and 2011.

RESULTS

For LHSA, the median age at surgery was 1.4 years (0.2-7.3), and the median follow-up time was 7.1 years (5-11.3). For LSP, the median age at surgery was 1.2 years (0.1-6.2) and the median follow-up time was 7.0 years (5-9.3). Constipation was less frequent after LHSA than after LSP (7.1 versus 22.2%, P = .025), but there was no difference in the frequency of soiling after LHSA compared with that after LSP (8.9 versus 14.8%, P = .339).

CONCLUSIONS

The improved anastomosis (LHSA) preserves most of the internal anal sphincter, and the wide anastomosis prevents stenosis as well. In the long-term follow-up results, the incidence of constipation after LHSA declined when compared with that after LSP, and soiling showed a satisfactory result. Our medical center has performed laparotomy-assisted heart-shaped anastomosis since the 1990s and LHSA since the 2000s. Because it is easy to learn and provide good outcomes, many medical centers in China have adopted the heart-shaped anastomosis to treat HD. Using the LHSA method to manage the affected bowel provides satisfactory long-term outcomes, that is, avoiding constipation and soiling. Thus, LHSA may provide a new choice for HD operations.

Hirschsprung disease - integrating basic science and clinical medicine to improve outcomes

Hirschsprung disease is defined by the absence of enteric neurons at the end of the bowel. The enteric nervous system (ENS) is the intrinsic nervous system of the bowel and regulates most aspects of bowel function. When the ENS is missing, there are no neurally mediated propulsive motility patterns, and the bowel remains contracted, causing functional obstruction. Symptoms of Hirschsprung disease include constipation, vomiting, abdominal distension and growth failure. Untreated disease usually causes death in childhood because bloodstream bacterial infections occur in the context of bowel inflammation (enterocolitis) or bowel perforation. Current treatment is surgical resection of the bowel to remove or bypass regions where the ENS is missing, but many children have problems after surgery. Although the anatomy of Hirschsprung disease is simple, many clinical features remain enigmatic, and diagnosis and management remain challenging. For example, the age of presentation and the type of symptoms that occur vary dramatically among patients, even though every affected child has missing neurons in the distal bowel at birth. In this Review, basic science discoveries are linked to clinical manifestations of Hirschsprung disease, including partial penetrance, enterocolitis and genetics. Insights into disease mechanisms that might lead to new prevention, diagnostic and treatment strategies are described.

Are all patients with short segment Hirschsprung's disease equal? A retrospective multicenter study

BACKGROUND/PURPOSE

Short segment Hirschsprung's disease (HSCR) carries a better prognosis than long segment disease, but the definition of short is controversial. The objective of this study is to determine anatomically the extent of disease involvement that would be associated with a better functional outcome.

METHODS

This is a retrospective multicenter (n = 3) study with patients (≥ 3 years) who had transanal pullthrough operation done for aganglionosis limited to the recto-sigmoid colon were reviewed. The extent of disease involvement and bowel resection was retrieved by reviewing the operative records as well as histopathological reports of the resected specimens. Clinical assessment was performed according to the criteria of a seven-itemed bowel function score (BFS) (maximum score = 20). Manometric assessment was performed with anorectal manometry.

RESULTS

The study period started from 2003 to 45 patients were studied with median age at assessment = 52.0 months and operation = 3.0 months. The disease involvement was categorized into upper sigmoid-descending colon (DC) (n = 8), sigmoid colon (SC) (n = 12), upper rectum (UR) (n = 14) and lower rectum (LR) (n = 11) according to the level of normal biopsy result. There was no significant difference in the age of assessment between the four groups. The median BFSs in the DC, SC, UR and LR were 13, 15, 17 and 17, respectively (p = 0.01). Nine patients from the DC and SC groups reported soiling for more than twice per week. Sub-group analysis comparing patients with and without the entire sigmoid colon resected revealed worse functional outcomes in terms of the incidence of soiling (40.7 vs 22.2%, p = 0.05) and the BFS (14 vs 18, p = 0.04) in the former group. Anorectal manometry did not reveal any significant difference between the four groups, but a higher proportion of patients in the UR and LR groups appeared to have a normal sphincter resting pressure (DC vs SC vs UR vs LR = 62.5 vs 75.0 vs 85.7 vs 80.0%, p = 0.10).

CONCLUSION

Patients with short segment HSCR are not equal at all. HSCR patients with aganglionosis limited to the rectum without the need of removing the entire sigmoid colon have a better bowel control and overall functional score. Less bowel loss and colonic dissection maybe the underlying reasons. Although future studies with a larger sample size and a longer follow-up period are required to validate the results of this study, it has provided a new insight to the current understanding of short segment disease in HSCR.

Down-regulation of fibronectin and the correlated expression of neuroligin in hirschsprung disease

AIM

The goal of this study was to investigate the expression of fibronectin (FN) and the correlated abundance of neuroligins (NLs) in the enteric nervous system (ENS) and to find a novel diagnostic marker in the serum of Hirschsprung disease (HSCR) patients.

METHODS

The expression levels of FN, neuroligin-1 and neuroligin-2 were detected in 114 children with or without HSCR. The expression and localization of the NLs and FN were assessed morphologically by immunohistochemical staining. Western blot analysis and real-time fluorescence quantitative PCR (qPCR) were performed to examine the correlated expression of the NLs and FN in aganglionic, transitional, and normal ganglionic colon tissues. An enzyme-linked immunosorbent assay (ELISA) was performed to evaluate and compare serum FN levels between HSCR and non-HSCRand between long-type HSCR and short-type HSCR.

RESULTS

These studies showed that both neuroligin-1 and neuroligin-2 were expressed at low levels in aganglionic segments and at intermediate levels in transitional segments compared to their high level of expression in normal tissue. In contrast, FN expression was negatively correlated, with expression in these three samples transitioning from highest to lowest. The serum FN level was higher in HSCR than in non-HSCR, but no significant difference between short-type HSCR and long-type HSCR was observed.

CONCLUSION

FN affects the expression of both neuroligin-1 and neuroligin-2 in HSCR, which may lead to the hypoplasia of ganglion cells in the ENS. This correlation may play a key role in the pathogenesis, diagnosis, or classification of HSCR.

Motility disorders in infants

Gastrointestinal motility disorders are common in the pediatric population and may affect the entire gastrointestinal tract and can vary from mild to severe conditions. They may clinically manifest as gastro-esophageal reflux symptoms, feeding difficulties and failure to thrive, constipation and diarrhea amongst others. This review first highlights the embryologic development of the gastrointestinal tract, after which the prenatal and neonatal development of gastrointestinal motility is discussed. Normal motility patterns as seen in (preterm) infants are described as a background for the discussion of the most common congenital and acquired motility disorders in infancy. This review specifically focuses on the role of preterm birth on the development of these disorders.

Rectal suction biopsy with calretinin immunohistochemistry in patients suspected with residual aganglionosis after operation for Hirschsprung disease

INTRODUCTION

This study investigates the use of rectal suction biopsy (RSB) with calretinin immunohistochemical staining (CIS) in patients suspected of having abnormally innervated bowel after pull through operation for Hirschsprung disease (HD).

METHOD

This study was conducted in Children's Hospital 2, Ho Chi Minh City from January 2015 through June 2016. Patients suspected with abnormally innervated bowel after pull through operation for HD were submitted for a RSB with CIS. Following histological results, the patients underwent an appropriate treatment (redo pull through operation or non-operative medical management) and followed up at least 6 months to evaluate their outcomes.

RESULTS

Ten patients were enrolled in our study. The median age was 5.6 (range 1.4-20) years. The diagnosis of normally innervated bowel was made in five patients by showing positive reactivity of CIS on RSB, whereas five others were diagnosed with abnormally innervated bowel. Final diagnosis of the five latter patients was confirmed by analyses of the resected bowel after a redo pull through operation (including 4 cases with residual aganglionosis and one case with transition zone bowel).

CONCLUSIONS

RSB with CIS is a reliable and simple method for diagnosis of abnormally innervated bowel after pull through operation for HD.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Study of diagnostic test (evaluate the effectiveness of a diagnostic test or outcome assessment).

Utility of Peripherin Versus MAP-2 and Calretinin in the Evaluation of Hirschsprung Disease

Hirschsprung disease (HD) is a congenital malformation resulting from the lack of migration of ganglion cells in the colon. The absence of ganglion cells in rectal suction biopsies aids in diagnosis, but evaluation of these small biopsies can be difficult. In this study, we compare the microtubule-associated protein-2 (MAP-2), calretinin, and peripherin immunohistochemical stains in 237 selected biopsies performed to rule out HD. By H&E stain, a total of 78 biopsies had ganglion cells, whereas 83 biopsies had no ganglion cells, and an additional 76 biopsies were equivocal for ganglion cells. Of the 78 biopsies with ganglion cells, MAP-2 was positive in 73 (94%), calretinin in 76 (97%), and peripherin in 78 (100%). Of the 83 biopsies with no ganglion cells, calretinin and peripherin highlighted nerve fibrils and ganglion cells, respectively, in 3 biopsies, whereas MAP-2 was positive in only 1 biopsy. Of the 76 biopsies equivocal for ganglion cells, 16 cases were positive by all 3 stains, an additional case by both calretinin and peripherin, and 2 cases by peripherin only. All of the newly positive biopsies were from patients without HD. This study demonstrates that peripherin is superior in helping to rule out HD in these small biopsies, highlighting ganglion cells in virtually all cases with ganglion cells, whereas MAP-2 and calretinin are less sensitive for identification of ganglion cells and nerve fibrils, respectively. In patients with HD, a panel using calretinin and peripherin with or without MAP-2 may be most helpful in identifying transition zones.

Immunostaining for Hu C/D and CD56 is useful for a definitive histopathological diagnosis of congenital and acquired isolated hypoganglionosis

Isolated hypoganglionosis (IHG) has been proposed as a distinct entity with two subtypes: congenital IHG (CIHG) and acquired IHG (AIHG). However, due to the rarity of the disease and the lack of defining histological criteria, the concept of IHG is not widely accepted. We studied paraffin-embedded intestinal specimens from 79 patients diagnosed with Hirschsprung's disease (HD) (n = 49), CIHG (n = 25), and AIHG (n = 5) collected between January 1996 and December 2015. Histopathological diagnosis of HD, CIHG, and AIHG was confirmed by hematoxylin and eosin staining and immunohistochemical staining using Hu C/D and CD56. We evaluated (immuno)histopathological findings, counted the number of ganglion cells, and measured the size of Auerbach's plexus. Hu C/D labeled neuronal cell bodies, whereas CD56 was detected in all neuronal components. In HD, all ganglion cells in Auerbach's plexus in the normoganglionic segment (NGS) were immunoreactive for Hu C/D, whereas in the aganglionic segment (AGS), these were replaced by CD56-positive extrinsic nerve fibers and bundles. The number of ganglion cells in AIHG and CIHG was significantly lower than in the NGS of HD (p < 0.05). Auerbach's plexus was significantly smaller in CIHG (p < 0.05) but in AIHG equivalent to the NGS in HD. In summary, immunostaining for Hu C/D and CD56 is useful for definitive histopathological diagnosis of IHG.

Pathological changes of interstitial cells of Cajal and ganglion cells in the segment of resected bowel in Hirschsprung's disease

OBJECTIVES

This study was conducted to investigate the pathological changes which occur in interstitial cells of Cajal (ICCs) and ganglion cells found in segments of resected bowel obtained from patients with Hirschsprung's disease (HD), as well as to explore the benefits of using a contrast enema (CE) with 24-h delayed X-ray films to predict the length of resected bowel.

METHODS

We performed a retrospective analysis of 58 children with HD who had undergone the pull-through procedure. After each operation, the ICCs and ganglion cells present in the proximal ends of the barium residue (Level A) and resected proximal bowel segment (Level B) were analyzed using immunohistochemical staining methods. Each patient was followed up for 1 year to record their stool frequency, defecation control ability, and post-surgical complications which may have occurred.

RESULTS

Immunohistochemical staining detected fewer ICCs in Level A than in Level B (p < 0.05). However, the density of ganglion cells in the two levels was not significantly different (p > 0.05). One patient had anastomotic stricture, and five patients suffered from enterocolitis.

CONCLUSIONS

The density of ICCs was significantly lower in the bowel segments that displayed barium retention. A CE may be a valuable tool for predicting the length of bowel resection in patients with HD.

Characterization of Intestinal Microbiomes of Hirschsprung's Disease Patients with or without Enterocolitis Using Illumina-MiSeq High-Throughput Sequencing

Hirschsprung-associated enterocolitis (HAEC) is a life-threatening complication of Hirschsprung's disease (HD). Although the pathological mechanisms are still unclear, studies have shown that HAEC has a close relationship with the disturbance of intestinal microbiota. This study aimed to investigate the characteristics of the intestinal microbiome of HD patients with or without enterocolitis. During routine or emergency surgery, we collected 35 intestinal content samples from five patients with HAEC and eight HD patients, including three HD patients with a history of enterocolitis who were in a HAEC remission (HAEC-R) phase. Using Illumina-MiSeq high-throughput sequencing, we sequenced the V4 region of bacterial 16S rRNA, and operational taxonomic units (OTUs) were defined by 97% sequence similarity. Principal coordinate analysis (PCoA) of weighted UniFrac distances was performed to evaluate the diversity of each intestinal microbiome sample. The microbiota differed significantly between the HD patients (characterized by the prevalence of Bacteroidetes) and HAEC patients (characterized by the prevalence of Proteobacteria), while the microbiota of the HAEC-R patients was more similar to that of the HAEC patients. We also observed that the specimens from different intestinal sites of each HD patient differed significantly, while the specimens from different intestinal sites of each HAEC and HAEC-R patient were more similar. In conclusion, the microbiome pattern of the HAEC-R patients was more similar to that of the HAEC patients than to that of the HD patients. The HD patients had a relatively distinct, more stable community than the HAEC and HAEC-R patients, suggesting that enterocolitis may either be caused by or result in a disruption of the patient's uniquely adapted intestinal flora. The intestinal microbiota associated with enterocolitis may persist following symptom resolution and can be implicated in the symptom recurrence.

Detection of autophagy in Hirschsprung's disease: implication for its role in aganglionosis

Hirschsprung's disease (HD) is a common congenital gastrointestinal malformation, characterized by the lack of ganglion cells from the distal rectum to the proximal bowel, but the pathogenesis is not well understood. This paper evaluates the effects of autophagy in HD. Using electron microscopy, the autophagosomes were detected in three segments: narrow segment (NS), transitional segment (TS), and dilated segment (DS). Typical autophagosome structures are found in the Auerbach plexus of both NS and TS. Real-time PCR results showed that Beclin1 (NS vs. TS, P<0.01) and LC3 (NS vs. TS, P<0.05) mRNA were the highest in the NS, but p75 (NS vs. TS, P<0.01) was the highest in the DS. Correlation analysis results showed a positive correlation between Beclin1 and LC3 mRNA levels (R=0.736, P=0.000), whereas inverse correlations were found between p75 and Beclin1/LC3 mRNA levels (p75 vs. Beclin1: R=-0.714, P=0.000; p75 vs. LC3: R=-0.619, P=0.000). Immunohistochemistry analyses indicated a consistent result with mRNA levels, by increased Beclin1-positive and LC3-positive neurons, but reduced p75-positive neurons in the Auerbach plexus of TS compared with DS. These findings indicated that autophagy exists in the bowel of patients with HD. On the basis of the detection of the highest expression of the autophagy genes in NS, autophagy may additionally cause the lack of neurons.

Novel Insights into the Pathogenesis of Hirschsprung's-associated Enterocolitis

OBJECTIVE

To systematically summary the updated results about the pathogenesis of Hirschsprung's-associated enterocolitis (HAEC). Besides, we discussed the research key and direction based on these results.

DATA SOURCES

Our data cited in this review were obtained mainly from PubMed from 1975 to 2015, with keywords "Hirschsprung enterocolitis", "Hirschsprung's enterocolitis", "Hirschsprung's-associated enterocolitis", "Hirschsprung-associated enterocolitis", "HAEC", and "EC".

STUDY SELECTION

Articles regarding the pathogenesis of HAEC were selected, and the articles mainly regarding the diagnosis, surgical approach, treatment, and follow-up were excluded.

RESULTS

Several factors, mainly including mucus barrier, intestinal microbiota, and immune function, as well as some other factors such as genetic variations and surgical reasons, have been found to be related to the pathogenesis of HAEC. Changed quantity and barrier property of mucus, different composition of microbiota, and an abnormal immune state work together or separately trigger HAEC.

CONCLUSIONS

The maintenance of intestinal homeostasis is due to a well cooperation of microbiota, mucus barrier, and immune system. If any part presents abnormal, intestinal homeostasis will be broken. Meanwhile, for patients with Hirschsprung's disease or HAEC, dysfunction of these parts has been found. Thus, the happening of HAEC may be mainly attributed to the disorders of intestinal microbiota, mucus barrier, and immune system.

Hirschsprung disease and hepatoblastoma: case report of a rare association

CONTEXT

Hirschsprung disease is a developmental disorder of the enteric nervous system that is characterized by absence of ganglion cells in the distal intestine, and it occurs in approximately 1 in every 500,000 live births. Hepatoblastoma is a malignant liver neoplasm that usually occurs in children aged 6 months to 3 years, with a prevalence of 0.54 cases per 100,000.

CASE REPORT

A boy diagnosed with intestinal atresia in the first week of life progressed to a diagnosis of comorbid Hirschsprung disease. Congenital cataracts and sensorineural deafness were diagnosed. A liver mass developed and was subsequently confirmed to be a hepatoblastoma, which was treated by means of surgical resection of 70% of the liver volume and neoadjuvant chemotherapy (ifosfamide, cisplatin and doxorubicin).

CONCLUSION

It is known that Hirschsprung disease may be associated with syndromes predisposing towards cancer, and that hepatoblastoma may also be associated with certain congenital syndromes. However, co-occurrence of hepatoblastoma and Hirschsprung disease has not been previously described. We have reported a case of a male patient born with ileal atresia, Hirschsprung disease and bilateral congenital cataract who was later diagnosed with hepatoblastoma.

How to manage a late diagnosed Hirschsprung's disease

BACKGROUND

How to manage a late diagnosed Hirschsprung's disease (HD) and how to avoid calibre discrepancy?

SUBJECTS AND METHODS

A retrospective study of all patients diagnosed with HD over 2 years in our hospital from January 2009 to December 2012. Data were analysed for clinical presentations, investigations, surgical procedures and post-operative outcome.

RESULTS

Fifteen patients, operated by one single surgeon, were included in this study. The mean age was 6 years (2-16 years). Patients had an ultra-short segment type in 4 cases, rectosigmoid type in 9 cases and descending colonic aganglionosis in 2 cases. Rectal wash out was effective in 12 patients. A blowhole transverse colostomy was performed in 2 patients. Twelve patients underwent one single stage endorectal pull-through. Anastomosis incongruence was avoided by a plication procedure never described before. The assessment of post-operative outcomes by the paediatric incontinence and constipation scoring system revealed a normal continence function in all our patients, but 3 patients suffered from soiling secondary to constipation.

CONCLUSION

One single stage pull-through can be safe and effective in children with late diagnosed HD. Routine rectal washout is a good way to prepare the colon. In some cases, blowhole colostomy can be an option. Anastomosis incongruence is a challenge; we describe a plication procedure to avoid it.