Out with the old and in with the new: a comparison of rectal suction biopsies with traditional and modern biopsy forceps

Systematic orientation of fresh rectal suction biopsies improves histopathological diagnostics in hirschsprung's disease - a method description and preliminary report

BACKGROUND

Optimizing rectal suction biopsy (RSB) diagnostics in Hirschsprung's disease (HD) may shorten diagnostic time and prevent need for repeated biopsies.

AIM

To explore whether systematic orientation of fresh RSB specimens increased biopsy quality, diagnostic times, diagnostic efficacy, and histopathologic workload, and to explore these outcome measures for aganglionic specimens.

MATERIALS/METHODS

This was an observational case-control study conducted at a national referral center for HD on data collected from the local HD-diagnostic register. From 2019 each fresh RSB was oriented by the collector in a notch in a foam cushion, placed in a separate cassette, and sent in formalin for pathological analysis. Outcome measures of oriented RSB samples collected 2019-2021 were compared to those of non-oriented RSB samples collected 2015-2018. Staining/immunohistochemistry consisted of hematoxylin eosin, S-100 and calretinin.

RESULTS

78 children with 81 RSBs and 242 biopsy analyzes were included. The frequency of high-quality RSB specimens was higher in oriented: 40% (42/106) versus non-oriented 25% (34/136) (p = 0.018), the diagnostic turnaround time was shorter: 2 days (1-5) versus 3 days (2-8) (p = 0.015), and the number of additional sectioning/leveling/re-orientation per biopsy was lower: 7 (3-26) versus 16 (7-72) (p = 0.011). Specifically for aganglionic specimens, the frequency of high-quality biopsies was generally higher in oriented than in non-oriented RSB specimens: 47% (28/59) versus 14% (7/50) (p < 0.001); the diagnostic efficacy was higher 95% (19/20) versus 60% (9/15) (p = 0.027) and the diagnostic turnaround time shorter: 2 days (2-3) versus 3 days (2-8) (p = 0.036).

CONCLUSIONS

Systematic orientation of fresh RSB specimens improves HD diagnostics. Improvement was consistent in aganglionic specimens.

Diagnostic Efficacy of Rectal Suction Biopsy with Regard to Weight in Children Investigated for Hirschsprung’s Disease

Background/aim: Diagnostic efficacy, defined as the percentage of rectal suction biopsy (RSB) specimens sufficient enough to determine the absence of ganglia cells in Hirschsprung’s disease (HD) diagnosis, has been reported to be low, requiring repeated biopsies. The aim was to explore whether RSB diagnostic efficacy was influenced by the child’s weight and to ascertain whether RSB efficacy differed between aganglionic and ganglionic tissue. Materials and Methods: Efficacy analyses were conducted in a national HD-center’s register on children 0–15 kg, examined between 2011–2019. First-time RSB diagnostic efficacy was correlated to the children’s weight and final HD diagnosis. Results: Among the 84 children who had first-time RSB, the overall diagnostic efficacy was 85% (71/84). The efficacy was higher among children weighing less than the identified cut-off of 9.0 kg (89% in 0–9.0 kg versus 62% in 9.01–15.0 kg, p = 0.026). Among children diagnosed with HD, 96% (26/27) weighed 0–9.0 kg. In this weight group, the diagnostic efficacy was lower in aganglionosis compared to ganglionosis (77%; 20/26 versus 96%; 43/45), p = 0.045). Conclusions: The RSB diagnostic efficacy was significantly higher in children weighing less than 9.0 kg and was less in aganglionic compared to ganglionic tissue. Therefore, weight can be useful to predict RSB diagnostic efficacy.

Bleeding after suction rectal biopsy with Rbi2: identification of the root cause through a multi-staged approach

Introduction

Suction rectal biopsy (SRB) is a key diagnostic tool in Hirschsprung’s disease. The original Noblett device has been superseded by modern alternatives including the Rbi2 rectal biopsy gun. We describe a comparison of biopsy results from the Noblett device and the Rbi2 gun and an investigation into significant post-biopsy bleeding episodes with the latter.

Methods

A retrospective review of SRB episodes between 2006 and 2014 was undertaken to audit biopsy success rates. Significant post-procedure bleeding after SRB with the Rbi2 gun prompted further investigations.

Results

Biopsies taken with the Noblett gun were more likely to be inadequate (Noblett 82/197 (40%) vs Rbi2 77/438 (18%)). After biopsy with the Rbi2 gun, 2 infants suffered from significant bleeding requiring resuscitation, blood product support and multiple theater episodes. As there were no reported cases of bleeding with the Rbi2 gun, a report was made to the Medicines & Healthcare products Regulatory Agency who identified incorrect biopsy technique as a potential contributing factor. A questionnaire of trainees and consultants found unexpected individual variation in SRB technique, with some users applying excessive suction.

Conclusions

Significant bleeding occurred after SRB with the Rbi2 gun, excessive suction was thought to be the cause.

Rectal Biopsy Technique for the Diagnosis of Hirschsprung Disease in Children: A Systematic Review and Meta-Analysis

ABSTRACT

The diagnosis of Hirschsprung disease (HD) depends on the histopathological analysis of rectal biopsies. This review aims to define the best rectal biopsy technique. A systematic literature review and proportional meta-analysis of the available case series studies of rectal biopsies were performed in this study. All case series with more than five rectal biopsies in children younger than 18 years of age suspected of HD that described at least one type of rectal biopsy were included. The studies that did not specify the rate of conclusive results and the rate of complications of the biopsy procedures were excluded. According to the literature review, there were four different techniques of rectal biopsy: open, suction, punch, and endoscopic. In the title and abstract screening process, we assessed 496 articles, 159 fulfilled the eligibility criteria, and 71 studies reported our outcomes of interest and were included in the meta-analysis. The pooled proportion of conclusive results was 94% in open biopsies (95% CI 0.89-0.98), 95% in punch (95% CI 0.90-0.98), and 88% in suction group (95% CI 0.85-0.92). The pooled proportion of complication rates was 2% in open biopsies (95% CI 0.00031-0.04), 0.039% in suction (95% CI 0.00023-0.0006), and 2% in punch biopsies (95% CI 0.00075-0.04). Suction, punch, and open techniques presented comparable rates of conclusive results. In the suction group, the association between different methods of histopathological analysis increased conclusive results rates; however, the punch biopsy was associated with significantly higher complication rates than the suction technique.

Comparison of inconclusive rates between suction rectal biopsy and open strip rectal biopsy in children of different age groups: a single-center retrospective study

Background

Rectal biopsy for the diagnosis for Hirschsprung's disease (HD) can be performed in several ways. Suction rectal biopsy (SRB) is the most widely used method for neonates and younger infants while open strip biopsy (OSB) is reserved for older children. Current notions suggest that SRB should not be used in older infants due to perceived thicker fibrous tissue in their rectal walls leading to higher rates of inconclusive results. This study aims to compare the inconclusive rates of both methods in children of different age groups.

Methods

A retrospective study were carried out with patients aged 13 years who underwent SRB or OSB during a 4-year period in a single center. Rectal biopsies were performed on patients with HD with previous endorectal pull-through surgeries excluded. Primary outcomes were rates of inconclusive results for SRB and OSB overall and when divided into different age groups.

Results

79 biopsies (57 SRB and 22 OSB) were included in the study. 12 biopsies (9 SRB and 3 OSB) were deemed inconclusive. There was no significant difference in the rate of inconclusive results between patients underwent SRB and OSB overall (15.8% vs 13.6%, p=1.000). The same results were obtained when patients were divided into under one year and over one year groups or other different age groups (30.0% vs 33.3%, p=1.000).

Conclusions

Despite low biopsy numbers, our study suggests that SRB provides comparable rates of inconclusive results with OSB in children of all age groups.

Full-thickness rectal biopsy in children suspicious for Hirschsprung's disease is safe and yields a low number of insufficient biopsies

INTRODUCTION

The diagnosis of Hirschsprung's disease (HD) relies on the histological demonstration of aganglionosis in the bowel wall. Biopsies may be obtained by rectal suction biopsy (RSB) or by transanal full-thickness excision biopsy (FTB). The objective of the present study was to evaluate the frequency of complications and inconclusive biopsies after FTB in children referred with suspicion of HD. The secondary objective was to calculate the frequency of proven aganglionosis.

METHODS

A retrospective chart review was performed of all patients under the age of 16years who underwent transanal FTB during the time period of 2008-2014.

RESULTS

A total of 555 patients were included in the review. Inconclusive biopsies were found at the primary biopsy in 35 patients (5.9%). Aganglionosis was found in 12% of the cases. The complication rate was 6.6% (39 patients), 85% of which were classified as a Clavien-Dindo I-II and 15% were classified as Clavien-Dindo III.

CONCLUSIONS

In this retrospective evaluation of FTB for the diagnosis of HD, the frequency of inconclusive biopsies at primary attempt was low and the complication rate was relatively high. However, most were minor complications.

LEVEL OF EVIDENCE

III.

Anorectal Manometry May Reduce the Number of Rectal Suction Biopsy Procedures Needed to Diagnose Hirschsprung Disease

OBJECTIVES

The aim of the study was to evaluate whether anorectal manometry (ARM), which is used to test the rectoanal inhibitory reflex (RAIR), is a safe alternative for reducing the number of invasive rectal suction biopsy (RSB) procedures needed to diagnose Hirschsprung disease (HD).

METHODS

Between 2010 and 2017, we prospectively collected the ARM results of 105 patients suspected of having HD. Following the outcome, the patients either underwent additional tests to confirm HD or they were treated conservatively. Primary ARM-based diagnoses were compared with the definitive diagnoses based on the pathology reports and/or clinical follow-ups. Additionally, we analyzed whether modifications to our ARM protocol improved diagnostic accuracy.

RESULTS

The sensitivity of ARM and RSB was comparable (97% vs 97%). The specificity of ARM, performed according to our initial protocol, was significantly lower than that of RSB. After we modified the protocol the difference between the specificity of ARM and RSB was no longer statistically significant (74% vs 84%, respectively, P = 0.260). The negative predictive value of ARM was 100%, while their positive predictive value was significantly lower than that of RSB (56% vs 97%, P < 0.001).

CONCLUSIONS

ARM is a viable screening tool for HD and, provided it is performed properly, it can be used to exclude HD with absolute certainty. By contrast, an absent rectoanal inhibitory reflex on ARM should always be followed by an RSB to confirm the diagnosis of HD. Using ARM as the diagnostic of first choice could reduce the number of invasive biopsies.

The evaluation of rectal mucosal punch biopsy in the diagnosis of Hirschsprung's disease: a 30-year experience of 954 patients

PURPOSE

For 30 years, we have consecutively performed rectal mucosal punch biopsy to diagnose Hirschsprung's disease. The aim of this study was to evaluate the safety of our technique.

METHODS

Patients with suspected Hirschsprung's disease who underwent punch biopsy, including our original "K-PUNCH" method using an S-moid forceps and non-specific blood-collecting tube at our department and branch hospital between April 1986 and March 2016 were included in the present study. Our punch biopsy technique is characterized by excellent visibility and a direct grasping sensation. The backgrounds and complications of the patients were retrospectively investigated.

RESULTS

During this period, 954 patients (median age 4 months; range 1 day-73 years) underwent punch biopsy. Although there were no cases of severe complications (i.e., rectal perforation, infection or full-thickness biopsy), one (0.1%) of the 954 cases in the early period showed liver dysfunction and required transfusion due to bleeding. In addition, inappropriate specimens were obtained in 37 patients (3.9%).

CONCLUSION

Punch biopsy including the "K-PUNCH" method is considered safe and feasible and is associated with a low rate of complications and inappropriate specimen harvesting among patients of all ages. Comorbidities, including the potential for hemorrhage, should always be considered.

Current practice patterns of rectal suction biopsy in the diagnostic work-up of Hirschsprung's disease: results from an international survey

PURPOSE

The diagnosis of Hirschsprung's disease (HD) was revolutionized by the introduction of rectal suction biopsy (RSB), allowing specimens to be taken without general anesthesia on the ward or as an out-patient procedure. However, insufficient tissue samples are not uncommon, and subsequently histopathologists often remain reluctant to confirm the presence or absence of enteric ganglion cells merely on the basis of submucosal RSBs. The aim of this study was to evaluate the current usage of RSB in the diagnostic work-up of HD based on an international survey.

METHODS

A 15-item questionnaire was distributed among participants and faculty members at the 21st International Meeting of the Pediatric Colorectal Society.

RESULTS

Eighty-seven pediatric surgeons from 30 countries completed the anonymous survey (response rate 70.2 %), grouped into 68 (78.2 %) staff surgeons and 19 (21.8 %) trainees, with a median work experience of 18 years (range 2-45 years). Of these, 74 (85.1 %) use RSB in the diagnostic work-up of patients with suspected HD, whereas 13 (14.9 %) prefer open full-thickness biopsy under general anesthesia. In total, 47 (63.5 %) respondents perform ≥20 RSBs (range 3-100 RSBs) per year. Five different RSB instruments were reported, the most common ones being rbi2 (65.0 %), Solo-RBT (15.0 %) and multipurpose suction biopsy kit (8.3 %). Only 22 (29.7 %) of the respondents use a defined negative suction pressure, with a median of 10 mL air (range 6-25 mL air). The most proximal reported biopsy site was located at a median of 2 cm (range 1-15 cm) above the pectinate line and a median of 2 (range 1-5) specimens are routinely taken, mainly from the posterior rectal wall. Insufficient tissue samples with need for repeat RSB were encountered in a median of 10 % (range 0-40 %). Most frequently used staining methods for rectal biopsies are hematoxylin/eosin (75.9 %), acetylcholinesterase (73.6 %), and calretinin (33.3 %). Overall, 36 (48.6 %) respondents had experienced RSB-related complications, including self-limiting rectal blood loss (n = 28), persistent rectal bleeding requiring blood transfusion (n = 9) and rectal perforation requiring surgical intervention (n = 7).

CONCLUSIONS

Although RSB is considered to be today's gold standard for the diagnosis of HD, many aspects of its current usage are lacking consensus. Therefore, a prospective multi-center study or larger global audit appears warranted to identify if the present survey reflects common surgical practice and to establish universal standards for RSB.

Suction rectal biopsy yields adequate tissue in children

BACKGROUND/PURPOSE

Hirschsprung disease (HD) is diagnosed by rectal biopsy, with suction rectal biopsy (SRB), the preferred technique in neonates. Reported SRB adequacy has varied overall with concern for decreased diagnostic yield in older children. The study aim was to assess SRB adequacy by age in children with the current device used at our institution.

METHODS

Following IRB approval, a retrospective cohort of children (1 to 18years) evaluated by SRB for HD was identified through billing records. Data regarding demographics, procedure, results, and complications were collected and analyzed using SPSS.

RESULTS

56 children (median age 3.9years) underwent SRB with an 80.4% overall success rate. Patients older than 5years had 90.5% adequacy rate compared to 74.3% in those younger. Univariate analysis revealed weak association of inadequate specimens with younger age and males, and no association with insurance, race/ethnicity, weight-height or BMI percentile, sedation type, or procedure location. SRB under general anesthesia (GA) had 100% adequacy (n=6). Patients with inadequate initial biopsy achieved diagnosis by SRB with increased sedation (n=5) or full thickness biopsy under GA (n=5).

CONCLUSION

With adequacy of 80.4% overall and 90.5% for patients greater than 5years, SRB is effective in evaluating the older child for HD.

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.

Rectal suction biopsy for the diagnosis of Hirschsprung's disease: a systematic review of diagnostic accuracy and complications

PURPOSE

Rectal suction biopsy (RSB) combined with acetylcholinesterase (AChE) staining is currently the gold standard for the diagnosis of Hirschsprung's disease (HD). However, some pathologists are still reluctant to diagnose HD in RSBs as it requires thick submucosal tissue to confirm the absence of ganglion cells. Furthermore, insufficient specimens and adverse events have been reported. The objective of this study was to determine the diagnostic accuracy and incidence of complications of RSBs in patients suspected of HD based on a systematic review of the published literature.

METHODS

A literature-based search for relevant publications was conducted using multiple online databases. Staining for AChE/hematoxylin and eosin should have been used to evaluate RSBs. The number of true-positive, false-positive, true-negative and false-negative results was recorded and data on RSB-related complications was extracted. Pooled incidence rates and odds ratios (ORs) with 95% confidence intervals (CI) were calculated using standardized statistical methodology.

RESULTS

Fifty-eight studies met defined inclusion criteria, reporting a total of 14,053 RSBs. The median cohort size consisted of 72 patients (range 1-766) with a median age of 14.4 months (range 1 day-66 years) at time of biopsy. In 89.93% (CI 89.11-90.70%), RSB provided adequate tissue for the diagnosis of HD. Insufficient specimens were obtained in 10.07% (CI 9.30-10.89%) and in 8.46 % (CI 7.55-9.46%) RSB was repeated. The incidence of HD was 19.13% (CI 18.25-20.03%). Mean sensitivity of RSB was 96.84% (CI 95.57-97.47%) and mean specificity was 99.42% (CI 99.17-99.57%). The overall complication rate was 0.65% (CI 0.46-0.91%) with persistent rectal bleeding requiring blood transfusion in 0.53% (CI 0.36-0.77%), bowel perforation in 0.06% (CI 0.02-0.18%) and pelvic sepsis in 0.06% (CI 0.02-0.18%). Complications were significantly more frequent in newborns and infants compared to older children (OR 9.00 [CI 4.75-17.07], p < 0.0001).

CONCLUSIONS

RSB combined with AChE staining is a simple, safe and accurate method for the diagnosis of HD. The risk for RSB-related complications is higher in newborns and infants.

Specific serum microRNA profile in the molecular diagnosis of Hirschsprung's disease

Hirschsprung's disease (HSCR), a congenital gastrointestinal disorder, is one of the most common causes of neonatal bowel obstruction. Without an early screening and diagnosis, some patients develop serious complications, such as toxic megacolon or acute enterocolitis. We sought to identify specific serum microRNAs (miRNAs) that can serve as novel early, non-invasive screening signature and then to test their specificity and sensitivity in diagnosing Hirschsprung's disease. We obtained serum samples from 95 HSCR cases and 104 matched controls. An initial screening of miRNA expression was performed through TaqMan Low Density Array. The candidate miRNAs were validated by individual reverse transcription quantitative real-time PCR arranged in the training and a two-stage validation set. Additional double-blind testing was performed in 23 patients with clinically suspected HSCR to evaluate the diagnostic value and accuracy of the serum miRNA profile in predicting HSCR. Following a multi-stage evaluation approach, five miRNAs were significantly increased in HSCR cases compared with controls. The areas under the receiver operating characteristic (ROC) curve of this five-serum miRNA signature were 0.895, 0.893 and 0.925 in training set and two validation sets, respectively. The accuracy rate of the five-miRNA profile as HSCR signature was 82.6%, which, in the double-blind testing set, was markedly higher than that of contrast enema (70%), the most commonly used test performed to diagnose HSCR. Our results indicate that a five-serum miRNA signature may be linked to HSCR, representing a potential, novel, non-invasive diagnostic approach for early screening of HSCR.

Does calretinin immunohistochemistry reduce inconclusive diagnosis in rectal biopsies for Hirschsprung disease?

Many difficulties occur during the evaluation of rectal biopsies for the diagnosis of Hirschsprung disease. We investigated whether the introduction of calretinin (CR) immunohistochemistry in a diagnostic panel could decrease the rate of inconclusive results. Data from 82 patients undergoing rectal biopsies before and after CR introduction were analyzed. Inconclusive results were obtained in 17 of 45 rectal biopsies (37.8%) in the series of cases before CR introduction and in 5 of 42 rectal biopsies (11.9%) in the series of cases after CR (P < 0.006). The inclusion of CR in the histopathologic panel may improve the diagnostic accuracy of Hirschsprung disease.

Hirschsprung disease in the older child: diagnostic strategies

BACKGROUND

Hirschsprung disease is usually diagnosed in patients who are younger than 1 year; but in some individuals it is found later in childhood.

OBJECTIVE

This retrospective study is focused on clinical signs and symptoms of Hirschsprung disease in older children.

MATERIALS AND METHODS

Patients with Hirschsprung disease were included in the study if they were older than 14 months at the time of diagnosis.

RESULTS

Ten patients older than 14 months were diagnosed with Hirschsprung disease; 7 were males and 3 females. In all, 60% had a positive history of recurrent gastrointestinal infection with vomiting and hospitalization. In 6 patients, the final diagnosis was delayed because of unspecific findings in contrast enema. Rectal biopsy confirmed the diagnosis in all patients.

CONCLUSION

Contrast enema is not a specific method for diagnosing Hirschsprung disease. Rectal biopsy alone confirms the diagnosis and provides a clear indication for surgery.