Heart-shaped anastomosis for Hirschsprung's disease: Operative technique and long-term follow-up

AIM: To study the long-term therapeutic effect of 'heartshaped' anastomosis for Hirschsprung's disease.METHODS: From January 1986 to October 1997, we performed one-stage 'heart-shaped' anastomosis for 193 patients with Hirschsprung's disease (HD). One hundred and fiftytwo patients were followed up patients (follow-up rate 79%).The operative outcome and postoperative complications were retrospectively analyzed.RESULTS: Early complications included urine retention in 2patients, enteritis in 10, anastomotic stricture in 1, and intestinal obstruction in 2. No infection of abdominal cavity or wound and anastomotic leakage or death occurred in any patients. Late complications were present in 22 cases,including adhesive intestinal obstruction in 2, longer anal in 5, incision hernia in 2, enteritis in 6, occasional stool stains in 7 and 6 related with improper diet. No constipation or incontinence occurred in any patient.CONCLUSION: The early and late postoperative complication rates were 7.8% and 11.4% respectively in our 'heartshaped anastomosis' procedure. 'Heart-shaped'anastomosis procedure for Hirschsprung's disease provides a better therapeutic effect compared to classic procedures.

Abundance and significance of neuroligin-1 and glutamate in Hirschsprung's disease

AIM: To investigate the abundance and potential diagnostic significance of neuroligin-1 and glutamate(Glu) in Hirschsprung's disease(HSCR).METHODS: Ninety children with HSCR and 50 children without HSCR matched for similar nutritional status, age and basal metabolic index were studied. The expression and localization of neuroligin-1 and Glu were assessed using double-labeling immunofluorescence staining of longitudinal muscles with adherent myenteric plexus from the surgically excised colon of children with HSCR. Western blot analysis, quantitative real-time PCR(q RT-PCR) and immunohistochemistry were performed to evaluate the abundance of neuroligin-1 and Glu in different HSCR-affected segments(ganglionic, transitional, and aganglionic segments). Enzyme-linked immunosorbent assay(ELISA) was used to detect and compare serum Glu levels in the long-segment HSCR, short-segment HSCR and non-HSCR samples.RESULTS: Neuroligin-1 and Glu were co-expressed highest to lowest in the ganglionic, transi tional and aganglionic segments based on Western blot(neuroligin-1: 0.177 ± 0.008 vs 0.101 ± 0.006, 0.177 ± 0.008 vs 0.035 ± 0.005, and 0.101 ± 0.006 vs 0.035 ±0.005, P < 0.005; Glu: 0.198 ± 0.006 vs 0.115 ± 0.008, 0.198 ± 0.006 vs 0.040 ± 0.003, and 0.115 ± 0.008 vs 0.040 ± 0.003, P < 0.005) and q RT-PCR(neuroligin-1: 9.58 × 10-5 ± 9.94 × 10-6 vs 2.49 × 10-5 ± 1.38 × 10-6, 9.58 × 10-5 ± 9.94 × 10-6 vs 7.17 × 10-6 ± 1.12 × 10-6, and 2.49 × 10-5 ± 1.38 × 10-6 vs 7.17 × 10-6 ± 1.12 × 10-6, P < 0.005). Serum Glu level was the highest to lowest in the non-HSCR, short-type HSCR and long-type HSCR samples based on ELISA(in nmol/μL, 0.93 ± 0.31 vs 0.57 ± 0.25, 0.93 ± 0.31 vs 0.23 ± 0.16, and 0.57 ± 0.25 vs 0.23 ± 0.16, P < 0.005).CONCLUSION: Neuroligin-1 and Glu may represent new markers of ganglion cells, whose expression may correlate with the pathogenesis, diagnosis, differential diagnosis or classification of HSCR.

Polymerase chain reaction-single strand conformational polymorphism analysis of rearranged during transfection proto-oncogene in Chinese familial hirschsprung's disease

AIM: To investigate the relationship between mutations of rearranged during transfection (RET) proto-oncogene and Chinese patients with Hirschsprung's disease (HD), and to elucidate the genetic mechanism of familial HD patient at the molecular level.METHODS: Genomic DNA was extracted from venous blood of probands and their relatives in two genealogies.Polymerase chain reaction (PCR) products, which were amplified using specific primers (RET, exons 11, 13, 15and 17), were electrophoresed to analyze the single-strand conformational polymorphism (SSCP) patterns. The positive amplified products were sequenced. Forty-eight sporadic HD patients and 30 normal children were screened for mutations of RET proto-oncogene simultaneously.RESULTS: Three cases with HD in one family were found to have a G heterozygous insertion at nucleotide 18 974 in exon 13 of RET cDNA (18 974insG), which resulted in a frameshift mutation. In another family, a heterozygosity for T to G transition at nucleotide 18 888 in the same exon which resulted in a synonymous mutation of Leu at codon 745 was detected in the proband and his father. Eight RET mutations were confirmed in 48 sporadic HD patients.CONCLUSION: Mutations of RET proto-oncogene may play an important role in the pathogenesis of Chinese patients with HD. Detection of mutated RET proto-oncogene carriers may be used for genetic counseling of potential risk for HD in the affected families.

Distribution of nitric oxide synthase, nerve growth factor receptor and interstitial cells of Cajal in hirschsprung's disease and its significance

Objective To investigate the distribution of nitric oxide synthase (NOS), nerve growth factor receptor (NGFR) and interstitial cells of Cajal (ICCs) in Hirschsprung’s disease (HD). Methods The distribution of NOS, NGFR and ICCs was studied by using NADPH diaphorase histochemistry, immunohistochemistry with a monoclonal antibody to human NGFR and the specific polyclonal antibody against c-kit in 8 normal controls and 10 cases of HD. Results NOS and NGFR were abundantly present in the myenteric plexus and in the nerve fibers of musculature. ICCs were intensively distributed in the surface of circular musculature and around the myenteric plexus to form a network in normal control colon. In contrast, NOS and NGFR were scarce or absent in the myenteric plexus and in the nerve fibers of musculature, while the hypertrophic nerve trunks were NGFR positive, ICCs were scarcely distributed and the network was disrupted in the aganglionic colon in HD. Conclusion These findings suggest the involvement of NOS, NGFR and ICCs in the pathophysiology of HD.

An Experimental Study on the Expression of Heme Oxygenase-2 mRNA in Hirschsprung's Disease

Summary: In order to investigate the relationship between the expression of heme oxygenase-2 (HO-2) mRNA and the pathogenesis of Hirschsprung's disease (HD), total ribonucleic acid (RNA) was extracted in the aganglionic and ganglionic segments of colon respectively from 15 cases of HD. The single-stranded cDNA of HO-2 was synthesized and further amplified by reverse transcription-polymerase chain reaction (RT-PCR). The expression of HO-2 mRNA was normal in ganglionic segments, but absent in aganglionic segments. It is concluded that the absence of HO-2 mRNA expression may be an important mechanism responsible for HD.

Comprehensive characterization of the genetic landscape of familial Hirschsprung's disease

Background Hirschsprung's disease(HSCR)is one of the most common congenital digestive tract malformations and can cause stubborn constipation or gastrointestinal obstruction after birth,causing great physical and mental pain to patients and their families.Studies have shown that more than 20 genes are involved in HSCR,and most cases of HSCR are sporadic.However,the overall rate of familial recurrence in 4331 cases of HSCR is about 7.6%.Furthermore,familial HSCR patients show incomplete dominance.We still do not know the penetrance and genetic characteristics of these known risk genes due to the rarity of HSCR families.Methods To find published references,we used the title/abstract terms"Hirschsprung"and"familial"in the PubMed data-base and the MeSH terms"Hirschsprung"and"familial"in Web of Science.Finally,we summarized 129 HSCR families over the last 40 years.Results The male-to-female ratio and the percentage of short segment-HSCR in familial HSCR are much lower than in sporadic HSCR.The primary gene factors in the syndromic families are ret proto-oncogene(RET)and endothelin B receptor gene(EDNRB).Most families show incomplete dominance and are relevant to RET,and the RET mutation has 56%pen-etrance in familial HSCR.When one of the parents is a RET mutation carrier in an HSCR family,the offspring's recurrence risk is 28%,and the incidence of the offspring does not depend on whether the parent suffers from HSCR.Conclusion Our findings will help HSCR patients obtain better genetic counseling,calculate the risk of recurrence,and provide new insights for future pedigree studies.

Identifying key genes associated with Hirschsprung's disease based on bioinformatics analysis of RNA-sequencing data

Background:Hirschsprung's disease (HSCR) is a type of megacolon induced by deficiency or dysfunction of ganglion cells in the distal intestine and is associated with developmental disorders of the enteric nervous system.To explore the mechanisms of HSCR,we analyzed the RNA-sequencing data of the expansion and the narrow segments of colon tissues separated from children with HSCR.Methods:RNA-sequencing of the expansion segments and the narrow segments of colon tissues isolated from children with HSCR was performed.After differentially expressed genes (DEGs) were identified using the edgeR package in R,functional and pathway enrichment analyses of DEGs were carried out using DAVID software.To further screen the key genes,protein-protein interaction (PPI) network and module analyses were conducted separately using Cytoscape software.Results:A total of 117 DEGs were identified in the expansion segment samples,including 47 up-regulated and 70 down-regulated genes.Functional enrichment analysis suggested that FOS and DUSP1 were implicated in response to endogenous stimulus.In the PPI network analysis,FOS (degree=20),EGR1 (degree=16),ATF3 (degree=9),NOS1 (degree=8),CCL5 (degree=8),DUSP1 (degree=7),CXCL3 (degree=6),VIP (degree=6),FOSB (degree=5),and NOS2 (degree=4) had higher degrees,which could interact with other genes.In addition,two significant modules (module 1 and module 2) were identified from the PPI network.Conclusion:Several genes (including FOS,EGR1,ATF3,NOS1,CCL5,DUSP1,CXCL3,VIP,FOSB,and NOS2) might be involved in the development of HSCR through their effect on the nervous system.

Preliminary identification of key miRNAs, signaling pathways, and genes associated with Hirschsprung's disease by analysis of tissue microRNA expression profiles

Background:Hirschsprung's disease (HSCR) is a congenital gut motility disorder of infants,and if left untreated,it is fatal to the affected infants.This study aimed to identify key microRNAs (miRNAs),signaling pathways and genes involved in the pathogenesis of HSCR.Methods:The miRNA microarray dataset GSE77296 was downloaded.Nine colon tissue samples were available:six from HSCR patients and three matched control samples.Differentially expressed miRNAs (DEMs) were identified after data preprocessing.Target genes of the selected upregulated and downregulated DEMs were predicted.In addition,functional enrichment analyses for the selected DEMs and target genes were conducted.Finally,interaction networks between the DEMs and target genes were constructed.Results:A total of 162 DEMs (73 upregulated and 89 downregulated) were obtained.A total of 2511 DEM-target gene pairs for the 40 selected DEMs were identified,including 1645 pairs for the upregulated DEMs and 866 pairs for the downregulated DEMs.The upregulated DEM miR-141-3p and down-regulated DEM miR-30a-3p were identified as key miRNAs by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment and network analyses.Besides,KEGG pathway enrichment analysis revealed that pathways in cancer and the mitogen-activated protein kinase (MAPK) signaling pathway were key pathways.The key genes frizzled class receptor 3 (FZD3) and docking protein 6 (DOK6) were obtained through the DEM-target gene interaction networks.Conclusion:Two key miRNAs (miR-141-3p and miR-30a-3p),the MAPK signaling pathway and two key genes (FZD3 and DOK6) were implicated in the pathogenesis of HSCR.

Rectal biopsy for Hirschsprung's disease:a review of techniques,pathology,and complications

Background:Hirschsprung's disease(HD)is one of the most common congenital anomalies of colorectal function,affecting approximately 1 in 5000 live births,with a 4:1 male predominance.HD is characterized by aganglionosis that is most often limited to the rectosigmoid,but can extend proximally along the colon and,in rare instances,reach into the small intestine.A clinical history of delayed passage of meconium beyond 48 hours after birth,physical exam findings of abdominal distention and vomiting,and a contrast enema demonstrating a transition zone are highly suggestive of HD.Data sources:We searched databases including PubMed,Google Scholar,and Scopus for the following key words:Hirschsprung's disease,rectal biopsy,pathology,ganglion cell,nerve trunk hypertrophy,pediatric constipation,and selected publications written in English that were relevant to the scope of this review.Results:Based on the data presented in the literature,we reviewed 1)biopsy techniques for the diagnosis of Hirschsprung's disease,addressed inadequate biopsies,and complications from rectal biopsy,and 2)pathologic and histologic interpretation of biopsy specimens for the diagnosis of Hirschsprung's disease.Conclusion:A well-executed rectal biopsy with expert pathologic evaluation of the specimen remains the gold standard for the diagnosis of Hirschsprung's disease and is the subject of this review.

Treatment of Adult Hirschsprung's Disease by Botulinum Toxin A through Anorectal Injection

To the Editor:The patient was a 16-year-old adolescent boy who was diagnosed with congenital megacolon.He had difficulty with defecating for more than 10 years.His bowel movements stopped more than 1 week ago.He was admitted to the hospital with incomplete intestinal obstruction.The patient showed signs of moderate nutrition,poor mental health,and full abdominal bulging and had an abdominal circumference of 104 cm. Rectal examination showed blasting exhaust and defecation, and the anal pressure measurement value was 89 mmHg.The total abdominal augmentation computed tomography and total colorectal sputum angiography showed that the upper and middle rectum,descending colon,transverse colon,and ascending colon were dilated,the maximum diameter of the intestine was 23 cm,and the intestine was filled with feces, suggesting that the lower rectum and sigmoid colon were narrow [Figure 1a and 1b].

The advances of genetics research on Hirschsprung's disease

Hirschsprung's disease(HSCR)is a rare and complex congenital disorder characterized by the absence of the enteric neurons in lower digestive tract with an incidence of 1/5 000.Affected infant usually suffer from severe constipation with megacolon and distended abdomen,and face long-term complications even after surgery.In the last 2 decades,great efforts and progresses have been made in understanding the genetics and molecular biological mechanisms that underlie HSCR.However,only a small fraction of the genetic risk can be explained by the identified mutations in the previously established genes.To search novel genetic alterations,new study designs with advanced technologies such as genome/exome-wide association studies(GWASs/EWASs)and next generation sequencing(NGS)on target genes or whole genome/exome,were applied to HSCR.In this review,we summaries the current development of the genetics researches on HSCR based on GWASs/EWASs and NGS,focusing on the newly discovered variants and genes,and their potential roles in HSCR pathogenesis.

Immunohistochemical study of P^(75NGFR) in Hirschsprung's disease

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Ikeda钉合法治疗先天性巨结肠症22例体会

目的 探讨Ikeda钉合法治疗小儿先天性巨结肠症的优缺点。方法 用Ikeda钉合法治疗小儿先天性巨结肠症 2 2例。结果 全组病例早期都有排便次数多 ,每天 4～ 15次不等 ,经过 2～ 4周都会恢复。其中 6例早期有污粪 ,1～ 3个月内恢复正常。远期无一例并发排便异常。结论 该法能够避免Ikeda环钳Ⅱ期吻合法带钳之苦 ,并有恢复快 。

Transumbilical enterostomy for Hirschsprung’s disease with a two-stage laparoscopy-assisted pull-through procedure

BACKGROUND A one-stage laparoscopic operation has recently been considered a favorable option for the management of patients with Hirschsprung's disease(HD)due to its superior cosmetic results.One-stage transanal endorectal pull-through for the treatment of rectosigmoid HD has been widely used in newborns without complications.However,enterostomy is required in some HD cases for enterocolitis and dilated colon.Our transumbilical enterostomy(TUE)and twostage laparoscopy-assisted anorectoplasty were effective and achieved a similar cosmetic effect to one-stage laparoscopy on the abdominal wall in patients with anorectal malformation,but the effect in patients with HD is unclear.AIM To evaluate the safety,efficacy and cosmetic results of TUE in two-stage laparoscopy-assisted pull-through for HD.METHODS From June 2013 to June 2018,53 patients(40 boys,13 girls;mean age at enterostomy:5.5±2.2 mo)who underwent enterostomy and two-stage laparoscopy-assisted pull-through for HD with stoma closure were reviewed at our institution.Two enterostomy approaches were used:TUE in 24 patients,and conventional abdominal enterostomy(CAE)in 29 patients.Eleven patients with rectosigmoid HD had severe preoperative enterocolitis or a dilated colon.26 patients had long-segment HD,and 16 patients had total colonic aganglionosis(TCA).The patients with left-sided HD underwent the two-stage laparoscopic Soave procedure,and the patients with right-sided HD and TCA underwent the laparoscopic Duhamel procedure.Demographics,enterostomy operative time,complications and cosmetic results were respectively evaluated.RESULTS There were no differences between the groups with respect to gender,age at enterostomy,weight and clinical type(P>0.05).No conversion to open technique was required.Two patients experienced episodes of stomal mucosal prolapse in the TUE group and 1 patient in the CAE group(8.33%vs 3.45%,P>0.05).No parastomal hernia was observed in either of the two groups.Wound infection at the stoma was seen in 1 case in the TUE group,and 2 cases in the CAE group(4.17%vs 6.90%,P>0.05).No obstruction was noted in any of the patients in the TUE group,whereas obstruction was found in 1 patient in the CAE group.Enterocolitis was observed in 3 and 5 patients in the TUE and CAE group,respectively(12.50%vs 17.24%,P>0.05).There was no significant difference between the TUE group and CAE group in terms of the incidence of soiling and constipation(P>0.05).The cosmetic result using the scar score in the TUE group was better than that in the CAE group(6.83±0.96 vs 13.32±1.57,P<0.05).CONCLUSION TUE is a safe and feasible method for the treatment of HD,and the staged enterostomy and two-stage laparoscopy-assisted pull-through achieved a similar cosmetic effect to the one-stage laparoscopic procedure.