背景:先天性巨结肠病(HD)表现为影响肠神经系统的发育异常,在肠道下部没有神经节细胞。这种缺陷导致肠道内的功能阻塞。HD通常通过直肠活检证实或排除。通过苏木精和曙红(H&E)染色鉴定任何神经节细胞排除HD。如果神经节细胞缺失,用乙酰胆碱酯酶(AChE)组织化学或钙视网膜素免疫组织化学(IHC)进一步染色是确定HD诊断的标准程序的一部分。2017年,我们海德堡大学医院病理学研究所将我们的HD诊断程序从AChE组织化学更改为calretininIHC。在本文中,我们报告了改变诊断程序对HD外科治疗程序和HD患者临床结局的影响.
方法:我们对诊断程序进行了回顾性审查,临床资料,29例小儿外科接受手术治疗的HD患者的术后进展,海德堡大学,2012年至2021年。患者样本分为两组,每个疗程为5年。在2012-2016年,仅使用AChE组织化学进行HD诊断(AChE组,n=17)。在2017-2021年,仅使用钙视网膜素IHC进行HD诊断(CR组,n=12)。
结果:两组性别分布无显著差异,妊娠数周,出生体重,神经节段的长度,或相关的先天性异常。AChE组几乎一半的孩子,是CR组的两倍,在经肛门直肠内牵拉术(TERPT)之前需要进行肠造口术。在AChE组中,4例患者(23.5%)需要重复肠道取样以确认诊断。与AChE组相比,CR组中更多的儿童在TERPT后出现便秘.
结论:在大多数HD患者中,AChE表达升高与神经节段的外源性胆碱能神经纤维肥大有关。AChE表达增加的表现随时间发展。因此,在新生儿HD患者中,尤其是在生命的前三周,未检测到AChE反应的增加。CalretininIHC可靠地识别神经节细胞的存在或不存在,并提供超过AChE组织化学的多种益处。这些包括对石蜡包埋的组织切片进行测试的能力,一个简单的染色模式,清晰的二元解释(否定或肯定),成本效益,和效用,无论患者年龄。
结论:钙视网膜素IHC早期和时间独立诊断HD的能力防止了我们患者人群中重复的肠道活检,并允许我们在生命的最初几个月进行一期TERPT,减少肠造口术的数量和早期恢复结肠连续性。年龄在3个月以下的患者需要密切随访以发现排便问题。
BACKGROUND: Hirschsprung disease (HD) manifests as a developmental anomaly affecting the enteric nervous system, where there is an absence of ganglion cells in the lower part of the intestine. This deficiency leads to functional blockages within the intestines. HD is usually confirmed or ruled out through rectal biopsy. The identification of any ganglion cells through hematoxylin and eosin (H&E) staining rules out HD. If ganglion cells are absent, further staining with acetylcholine-esterase (AChE) histochemistry or
calretinin immunohistochemistry (IHC) forms part of the standard procedure for determining a diagnosis of HD. In 2017, our Institute of Pathology at University Hospital of Heidelberg changed our HD diagnostic procedure from AChE histochemistry to
calretinin IHC. In this paper, we report the impact of the diagnostic procedure change on surgical HD therapy procedures and on the clinical outcome of HD patients.
METHODS: We conducted a retrospective review of the diagnostic procedures, clinical data, and postoperative progress of 29 patients who underwent surgical treatment for HD in the Department of Pediatric Surgery, University of Heidelberg, between 2012 and 2021. The patient sample was divided into two groups, each covering a treatment period of 5 years. In 2012-2016, HD diagnosis was performed exclusively using AChE histochemistry (AChE group, n = 17). In 2017-2021, HD diagnosis was performed exclusively using
calretinin IHC (CR group, n = 12).
RESULTS: There were no significant differences between the groups in sex distribution, weeks of gestation, birth weight, length of the aganglionic segment, or associated congenital anomalies. Almost half of the children in the AChE group, twice as many as in the CR group, required an enterostomy before transanal endorectal pull-through procedure (TERPT). In the AChE group, 4 patients (23.5%) required repeat bowel sampling to confirm the diagnosis. Compared to the AChE group, more children in the CR group suffered from constipation post TERPT.
CONCLUSIONS: Elevated AChE expression is linked to hypertrophied extrinsic cholinergic nerve fibers in the aganglionic segment in the majority of patients with HD. The manifestation of increased AChE expression develops over time. Therefore, in neonatal patients with HD, especially those in the first 3 weeks of life, an increase in AChE reaction is not detected.
Calretinin IHC reliably identifies the presence or absence of ganglion cells and offers multiple benefits over AChE histochemistry. These include the ability to perform the test on paraffin-embedded tissue sections, a straightforward staining pattern, a clear binary interpretation (negative or positive), cost-effectiveness, and utility regardless of patient age.
CONCLUSIONS: The ability of
calretinin IHC to diagnose HD early and time-independently prevented repeated intestinal biopsies in our patient population and allowed us to perform a one-stage TERPT in the first months of life, reducing the number of enterostomies and restoring colonic continuity early. Patients undergoing transanal pull-through under the age of 3 months require a close follow-up to detect cases with bowel movement problems.