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Controversies concerning diagnostic guidelines for anomalies of the enteric nervous system: A report from the fourth International Symposium on Hirschsprung's disease and related neurocristopathies

      Abstract

      Intestinal Dysganglionoses (IDs) represent a heterogeneous group of Enteric Nervous System anomalies including Hirschsprung's disease (HD), Intestinal Neuronal Dysplasia (IND), Internal Anal Sphincter Neurogenic Achalasia (IASNA) and Hypoganglionosis. At present HD is the only recognised clinico-pathological entity, whereas the others are not yet worldwide accepted and diagnosed. This report describes the areas of agreement and disagreement regarding definition, diagnosis, and management of IDs as discussed at the workshop of the fourth International Meeting on “Hirschsprung's disease and related neurochristopathies.”
      The gold standards in the preoperative diagnosis of IDs are described, enlighting the importance of rectal suction biopsy in the diagnostic workup. The most important diagnostic features of HD are the combination of hypertrophic nerve trunks and aganglionosis in adequate specimens. Acetylcholinesterase staining is the best diagnostic technique to demonstrate hypertrophic nerve trunks in lamina propia mucosae, but many pathologist from different centers still use H&E staining effectively. Moreover, the importance of an adequate intraoperative pathological evaluation of the extent of IDs to avoid postoperative complications is stressed. Although it is not clear whether IND is a separate entity or some sort of secondary acquired condition, it is concluded that both IND and IASNA do exist. Other interesting conclusions are provided as well as detailed results of the discussion. Further investigation is needed to resolve the many controversies concerning IDs. The fourth International Conference in Sestri Levante stimulated discussion regarding these entities and led to the International guidelines to serve the best interest of our patients.

      Index words

      Intestinal dysganglionoses (IDs) represent a heterogeneous group of anomalies of the enteric nervous system (ENS) including Hirschsprung's disease (HD), intestinal neuronal dysplasia (IND), internal anal sphincter neurogenic achalasia (IASNA), and hypoganglionosis.
      At present, internationally, the only widely recognized and accepted clinical-pathological entity is HD, whereas IND, IASNA, and hypoganglionosis are not yet accepted conditions, nor are these diagnosed by clinicians in many countries. “Are they true congenital malformations or acquired phenomena?” This is the major debate regarding the origins of these anomalies. Some authors firmly believe in the independent existence of all forms of IDs, for which they defined diagnostic criteria and proposed therapeutic protocols [
      • Puri P.
      • Wester T.
      Intestinal neuronal dysplasia.
      ,
      • Meier-Ruge W.
      • Gambazzi F.
      • Kaufeler R.E.
      • et al.
      The neuropathological diagnosis of neuronal intestinal dysplasia (NID B).
      ,
      • Martucciello G.
      • Torre M.
      • Pini Prato A.
      • et al.
      Associated anomalies in intestinal neuronal dysplasia.
      ,
      • Gillick J.
      • Tazawa H.
      • Puri P.
      Intestinal neuronal dysplasia: results of treatment in 33 patients.
      ]. Conversely, others maintain a critical position regarding these controversial conditions as they consider ENS anomalies as secondary acquired phenomena sometimes associated with other diseases such as bowel atresias, HD, or simple constipation [
      • Sacher P.
      • Briner J.
      • Hanimann B.
      Is neuronal intestinal dysplasia (NID) a primary disease or a secondary phenomenon?.
      ,
      • Huang C.C.
      • Ko S.F.
      • Chuang J.H.
      • et al.
      Lipoblastomatosis combined with intestinal neuronal dysplasia.
      ,
      • Galvez Y.
      • Skaba R.
      • Vajtrova R.
      • et al.
      Evidence of secondary neuronal intestinal dysplasia in a rat model of chronic intestinal obstruction.
      ].
      All the pathological features of ENS have been described in depth, and more than 70 diagnostic, enzymatic-histochemical, and immunohistochemical staining techniques have been proposed for ENS evaluation. These include H&E, acetylcholinesterase (AChE), rapid AChE, lactate dehydrogenase (LDH), succinic dehydrogenase, alphanaphtylesterase, and nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) [
      • Nogueira A.M.
      • Barbosa A.J.
      • Carvalho A.A.
      • et al.
      Usefulness of immunocytochemical demonstration of neuron-specific enolase in the diagnosis of Hirschsprung's disease.
      ,
      • Park W.H.
      • Choi S.O.
      • Kwon K.Y.
      • et al.
      Acetylcholinesterase histochemistry of rectal suction biopsies in the diagnosis of Hirschsprung's disease.
      ,
      • Kobayashi H.
      • O'Briain D.S.
      • Hirakawa H.
      • et al.
      A rapid technique of acetylcholinesterase staining.
      ,
      • Karnovsky M.J.
      • Roots L.
      A “direct coloring” thiocholine method for cholinesterase.
      ,
      • Martucciello G.
      • Favre A.
      • Torre M.
      • et al.
      A new rapid acetylcholinesterase histochemical method for the intraoperative diagnosis of Hirschsprung's disease and intestinal neuronal dysplasia.
      ,
      • Pini Prato A.
      • Martucciello G.
      • Jasonni V.
      Solo-RBT: a new instrument for rectal suction biopsies in the diagnosis of Hirschsprung's disease.
      ,
      • Martucciello G.
      • Mazzola C.
      • Favre A.
      • et al.
      Preoperative enzymo–histochemical diagnosis of dysganglionoses associated with anorectal malformations (ARM) with recto–vestibular and recto–perineal fistula.
      ,
      • Hirakawa H.
      • Kobayashi H.
      • O'Briain D.S.
      • et al.
      Absence of NADPH-diaphorase activity in internal anal sphincter (IAS) achalasia.
      ]. Peripherin, cathepsin D, PGP 9.5, synaptophysin, chromogranins, S-100 protein, 2 nerve markers-erythrocyte-type glucose transporter (GLUT-1), choline acetyltransferase, nerve growth factor receptor, neuron-specific enolase, neurofilaments, vasoactive intestinal peptide, neuropeptide galantine, substance P, neuropeptide Y, calcitonin gene–related peptide, gastrin releasing peptide, enkephalin (Met-ENK), and acridine orange comprise the numerous histochemical stains currently in use [
      • Nogueira A.M.
      • Barbosa A.J.
      • Carvalho A.A.
      • et al.
      Usefulness of immunocytochemical demonstration of neuron-specific enolase in the diagnosis of Hirschsprung's disease.
      ,
      • Petchasuwan C.
      • Pintong J.
      Immunohistochemistry for intestinal ganglion cells and nerve fibers: aid in the diagnosis of Hirschsprung's disease.
      ,
      • Kakita Y.
      • Oshiro K.
      • O'Briain D.S.
      • et al.
      Selective demonstration of mural nerves in ganglionic and aganglionic colon by immunohistochemistry for glucose transporter-1: prominent extrinsic nerve pattern staining in Hirschsprung disease.
      ,
      • Ratcliffe E.M.
      • deSa D.J.
      • Dixon M.F.
      • et al.
      Choline acetyltransferase (ChAT) immunoreactivity in paraffin sections of normal and diseased intestines.
      ,
      • Kobayashi H.
      • Hirakawa H.
      • O'Briain D.S.
      • et al.
      Nerve growth factor receptor staining of suction biopsies in the diagnosis of Hirschsprung's disease.
      ,
      • Romanska H.M.
      • Bishop A.E.
      • Brereton R.J.
      • et al.
      Immunocytochemistry for neuronal markers shows deficiencies in conventional histology in the treatment of Hirschsprung's disease.
      ,
      • Sarnat H.B.
      • Seagram G.F.
      • Trevenen C.L.
      • et al.
      A fluorochromic stain for nucleic acids to demonstrate submucosal and myenteric neurons in Hirschsprung's disease.
      ].
      Most of the hospital facilities dealing with IDs cannot afford the adoption of expensive and sophisticated staining techniques on a daily routine basis for ENS examination [
      • Meier-Ruge W.A.
      • Bruder E.
      Pathology of chronic constipation in pediatric and adult coloproctology.
      ] and, therefore, frequently use nonspecific histomorphological staining techniques such as H&E to diagnose HD.
      This report describes the areas of agreement and disagreement regarding definition, diagnosis, and management of IDs, discussed at a workshop of the fourth International Meeting on “Hirschsprung's disease and related neurocristopathies.” The aim is to focus on aspects of IDs for which some consensus among specialists in the field was achieved and some general guidelines developed. It is fully recognized, however, that this only represents a starting point for future important clinical and research studies.

      1. Materials and methods

      The workshop entitled “Criteria for Classification and Diagnosis of Dysganglionoses” was part of the fourth International Meeting on “Hirschsprung's disease and related neurocristopathies.” The meeting's participants included basic scientists, geneticists, pathologists, and pediatric surgeons. The meeting was held in Sestri Levante, Genoa, Italy, on April 22 to 24, 2004, and was organized as follows:
      Some of the most recognized authors in this field (W Meier-Ruge, P Puri, G Martucciello, and AM Holschneider) participated in a round table. The chairmen of the session (JL Grosfeld and JA Tovar) presented 10 items for debate regarding IDs to stimulate open discussion from the roundtable members and the audience. Approximately 150 participants joined in-depth discussion on each debated point. Among them were important investigators in the field such as K Georgeson, A Coran, R Kapur, H Kobayashi, A Chakravarti, P Tam, and MD Gershon (Fig. 1). The discussion was tape recorded (Fig. 2, Fig. 3).
      Figure thumbnail gr1
      Fig. 1Participants from every country and field were present to discuss different aspects on research and clinical features of IDs. From left to right, Stanislav Lyonnet and Aravinda Chakravarti (world famous geneticists).
      Figure thumbnail gr2
      Fig. 2The meeting was opened, with a keynote lecture describing the historical background of HD, by JL Grosfeld (pediatric surgeon) who also chaired the workshop on criteria for classification and diagnosis of intestinal dysganglionoses.
      Figure thumbnail gr3
      Fig. 3Experts from different countries participated at the meeting and discussed many topics during the workshop. From left to right, Juan Alberto Tovar, Prem Puri, and Vincenzo Jasonni (pediatric surgeons).
      The 10 debated topics included the following:
      • 1.
        Acetylcholinesterase is necessary for the diagnosis of HD.
      • 2.
        Rectal suction biopsy is adequate for the diagnosis of HD.
      • 3.
        Acetylcholinesterase should be associated with at least one other histochemical technique.
      • 4.
        Anorectal manometry is not a useful tool in the diagnosis of HD. It is much more useful when biopsies are negative for HD in order to exclude the possible diagnosis of IASNA.
      • 5.
        Barium enema is useful in deciding on the surgical approach rather than to confirm the diagnosis.
      • 6.
        Adequate intraoperative biopsy for histologic staining is mandatory during surgery of HD.
      • 7.
        At least one enzymatic-histochemical staining technique among LDH, nonspecific esterase, and rapid AChE should be used for intraoperative assessment.
      • 8.
        The diagnosis of IASNA is the result of a clinical, manometric, and histochemical studies.
      • 9.
        The most difficult diagnosis is hypoganglionosis. Without laparoscopic/or open seromuscular biopsies, it is very difficult to obtain a correct diagnosis.
      • 10.
        Does IND exist?
      A list of agreements/disagreements will be presented with important comments made during the discussion.

      2. Results

      These are the results of the discussion for each point raised during the workshop:
      • 1.
        European and Asian investigators (W Meier-Ruge, G Martucciello, P Puri, JA Tovar, A Holschneider and H Kobayashi) routinely use AChE to diagnose HD, whereas the American contingent (JL Grosfeld, K Georgeson, AG Coran, and R Kapur) think that H&E is more user friendly, cheaper, and more reliable for the diagnosis of HD. Although AChE is an extremely useful tool to diagnose HD, it seems that only very specialized centers can rely on this staining technique to diagnose HD.
      • 2.
        The unanimous opinion of the group was that rectal suction biopsy is the current gold standard in the diagnosis of HD.
      • 3.
        This point overlaps the first question concerning enzymatic-histochemistry and histomorphology. European and Asian participants were divided in opinion regarding the best other technique to use along with AChE (ie, LDH, NADPH-d, or others), whereas some American participants still believe that H&E is the only technique required to diagnose HD.
      • 4.
        Although there is broad agreement that anorectal manometry is unnecessary to diagnose HD, some still use manometry as an adjunct to help diagnose HD or as a study complement (JA Tovar). The discussion focused on the debated treatment options for IASNA, namely, botulinum toxin injection, anal dilatation, and sphincteromyectomy. Few participants were convinced that Botulinum toxin injection was an enduring treatment. There was general agreement on the importance of anal dilatation as first step in treatment. Sphincteromyectomy was the most debated option: some pediatric surgeons (A Holschneider, V Jasonni) avoid it in most cases because of the risk of incontinence. Others, however, (AG Coran, P Puri, JL Grosfeld) consider this procedure safe and effective in selected pediatric patients. Sphincteromyectomy may increase the risk of fecal incontinence in patients who have previously undergone anorectal surgery (A Holschneider, AG Coran).
      • 5.
        Everybody agreed that the barium enema was often useful in selecting the operative approach, but some think that the barium enema can sometimes be misleading in evaluating the proximal extent of aganglionic bowel (K Georgeson and AG Coran).
      • 6.
        Everybody agreed that an intraoperative biopsy was necessary, although controversies remain regarding which staining technique should be used (H&E or histochemical staining like LDH, NADPH-d, and nonspecific esterase).
      • 7.
        This point was not discussed at length as it overlaps the previous item.
      • 8.
        Everybody agreed on this point. Moreover, none excluded manometry as enzymatic-histochemistry, and histology alone cannot provide the diagnosis that is achieved by demonstrating the absence of the anal inhibitory reflex.
      • 9.
        There was broad agreement regarding the difficulty in diagnosing hypoganglionosis (A Holschneider, W Meier-Ruge, G Martucciello). Some participants did not think that hypoganglionosis really exists (AG Coran, JA Tovar) because they have never seen a case in their extensive experience.
      • 10.
        Almost all the participants believe that IND does exist. Some believe in presently defined diagnostic criteria (G Martucciello, W Meier-Ruge), whereas others suggest that these diagnostic criteria are not reliable enough (A Holschneider), referring to a report by Dr Coerdt that showed the presence of ENS anomalies similar to those of IND in perfectly healthy children (abstract entitled, “Quantitative morphometric analysis of the submucous plexus in age-related control groups”). Some participants question if IND is a truly separate entity or an acquired secondary phenomenon related to long-standing constipation or chronic obstruction (A Coran, K Georgeson, JL Grosfeld).
      The following comments were made by the chairman, JL Grosfeld, at the end of the session:“Well, the hour is late. We could ask other questions about IND and staining but I think this would be redundant since we've heard all about the different staining techniques before. There is a consensus about some of the issues we discussed today including: (1) You can make the diagnosis of HD with a submucosal biopsy, I think everybody would agree with that. There is a slight disagreement whether you need H&E alone or whether you need H&E plus other stains but that varies in different countries. (2) In regard to anorectal achalasia (IASNA), I believe there is consensus that you need the presence of ganglion cells and the absence of the anorectal inhibitory reflex to make that diagnosis. There are some controversies regarding treatment but at least to achieve the diagnosis we have consensus.(3) An intraoperative biopsy is necessary in patients with HD to make sure that you bring down bowel with normal ganglia. There is slight disagreement whether you evaluate the biopsy with an H&E stain alone and/or other special histochemical and enzymatic studies. However, everyone agrees you need an intraoperative biopsy. 4] Everyone agrees the diagnosis of hypoganglionosis is very difficult to make and some are not sure this entity actually exists. (5) Finally, I think there is general agreement that IND probably exists, whether it is a primary entity or a secondary phenomenon is yet to be determined.”

      3. Conclusions

      Hirschsprung's disease is a worldwide accepted entity whose diagnosis is based on rectal suction biopsy [
      • Pini Prato A.
      • Martucciello G.
      • Jasonni V.
      Solo-RBT: a new instrument for rectal suction biopsies in the diagnosis of Hirschsprung's disease.
      ]. This technique allows sampling of a mucosal-submucosal specimen required for proper ENS evaluation. The most important diagnostic features of HD are the combination of hypertrophic nerve trunks and aganglionosis in an adequate specimen. Acetylcholinesterase staining is the best diagnostic technique to demonstrate hypertrophic nerve trunks in lamina propria mucosae, but many pathologists from different centers still use H&E staining effectively. Newly developed diagnostic kits for enzymatic-histochemistry will likely increase the use of AChE for the diagnosis of HD. The new industrial kits lyophilize the components of the medium that can be sent at room temperature anywhere in the world (Hirschsprung's disease diagnostic kit, BIO-OPTICA, Milan, www.bio-optica.it).
      Although barium enema is not essential to confirm the diagnosis of HD; in many cases, it is useful in evaluating the level of aganglionosis and aids in the decision regarding the surgical approach (ie, transanal, transabdominal laparoscopic, or open). Although anorectal manometry is frequently used in association with rectal biopsy and barium enema in evaluating patients for HD, it is not routinely necessary. Anorectal manometry is more useful in the diagnostic workup of IASNA rather than HD.
      Intraoperative pathological evaluation of the extent of aganglionosis is mandatory to be sure that normal ganglionated bowel is used for a colostomy or pull through procedure. In some instances, intraoperative biopsies may also demonstrate the possible presence of associated proximal hypoganglionosis or IND.
      Internal anal sphincter neurogenic achalasia is a recognized entity characterized by the presence of normal ganglion cells in the submucosal plexus, slight reduction of NADPH-d activity, and absence of rectoanal inhibitory reflex in a severely constipated child. Treatment-wise, it seems clear that the patient should undergo initial anal dilatations. Myectomy can be used with good results expected in selected cases. Attention should be paid to children who underwent previous anorectal operations because their internal anal sphincter has presumably been damaged to some extent by the prior procedure. Further myectomy may increase the risk of incontinence.
      Hypoganglionosis is not yet considered as an isolated entity worldwide. Moreover, it is not clear whether it represents a severe form of ID or just an ENS abnormality that leads to constipation. There are divergent views concerning this condition in Asia (H Kobayashi) and Europe (G Martucciello), and further studies are necessary to reach a consensus on definition and diagnosis.
      Finally, IND likely does exist, although it is not clear as yet whether it is a separate primary entity or some sort of secondary acquired condition. Definition and diagnosis of IND are yet to be determined because more than one criterion has been proposed in recent years. Most authors suggest nonoperative conservative treatment in most cases. Treatment depends on clinical presentation of the patients: conservative treatment is sufficient in 90% of cases, but enterostomy may be necessary in about 10% of patients.
      Further investigation is needed to resolve the many controversies concerning IDs. The fourth International Conference in Sestri Levante stimulated discussion regarding these entities and led to the International Guidelines noted above as an effort serve the best interest of our patients.

      References

        • Puri P.
        • Wester T.
        Intestinal neuronal dysplasia.
        Semin Pediatr Surg. 1988; 7: 181-186
        • Meier-Ruge W.
        • Gambazzi F.
        • Kaufeler R.E.
        • et al.
        The neuropathological diagnosis of neuronal intestinal dysplasia (NID B).
        Eur J Pediatr Surg. 1994; 4: 267-273
        • Martucciello G.
        • Torre M.
        • Pini Prato A.
        • et al.
        Associated anomalies in intestinal neuronal dysplasia.
        J Pediatr Surg. 2002; 37: 219-223
        • Gillick J.
        • Tazawa H.
        • Puri P.
        Intestinal neuronal dysplasia: results of treatment in 33 patients.
        J Pediatr Surg. 2001; 36: 777-779
        • Sacher P.
        • Briner J.
        • Hanimann B.
        Is neuronal intestinal dysplasia (NID) a primary disease or a secondary phenomenon?.
        Eur J Pediatr Surg. 1993; 3: 228-230
        • Huang C.C.
        • Ko S.F.
        • Chuang J.H.
        • et al.
        Lipoblastomatosis combined with intestinal neuronal dysplasia.
        Arch Pathol Lab Med. 1998; 122: 191-193
        • Galvez Y.
        • Skaba R.
        • Vajtrova R.
        • et al.
        Evidence of secondary neuronal intestinal dysplasia in a rat model of chronic intestinal obstruction.
        J Invest Surg. 2004; 17: 31-39
        • Nogueira A.M.
        • Barbosa A.J.
        • Carvalho A.A.
        • et al.
        Usefulness of immunocytochemical demonstration of neuron-specific enolase in the diagnosis of Hirschsprung's disease.
        J Pediatr Gastroenterol Nutr. 1990; 11: 496-502
        • Park W.H.
        • Choi S.O.
        • Kwon K.Y.
        • et al.
        Acetylcholinesterase histochemistry of rectal suction biopsies in the diagnosis of Hirschsprung's disease.
        J Korean Med Sci. 1992; 7: 353-359
        • Kobayashi H.
        • O'Briain D.S.
        • Hirakawa H.
        • et al.
        A rapid technique of acetylcholinesterase staining.
        Arch Pathol Lab Med. 1994; 118: 1127-1129
        • Karnovsky M.J.
        • Roots L.
        A “direct coloring” thiocholine method for cholinesterase.
        J Histochem Cytochem. 1964; 12: 219
        • Martucciello G.
        • Favre A.
        • Torre M.
        • et al.
        A new rapid acetylcholinesterase histochemical method for the intraoperative diagnosis of Hirschsprung's disease and intestinal neuronal dysplasia.
        Eur J Pediatr Surg. 2001; 11: 300-304
        • Pini Prato A.
        • Martucciello G.
        • Jasonni V.
        Solo-RBT: a new instrument for rectal suction biopsies in the diagnosis of Hirschsprung's disease.
        J Pediatr Surg. 2001; 36: 1364-1366
        • Martucciello G.
        • Mazzola C.
        • Favre A.
        • et al.
        Preoperative enzymo–histochemical diagnosis of dysganglionoses associated with anorectal malformations (ARM) with recto–vestibular and recto–perineal fistula.
        Eur J Pediatr Surg. 1999; 9: 96-100
        • Hirakawa H.
        • Kobayashi H.
        • O'Briain D.S.
        • et al.
        Absence of NADPH-diaphorase activity in internal anal sphincter (IAS) achalasia.
        J Pediatr Gastroenterol Nutr. 1995; 20: 54-58
        • Petchasuwan C.
        • Pintong J.
        Immunohistochemistry for intestinal ganglion cells and nerve fibers: aid in the diagnosis of Hirschsprung's disease.
        J Med Assoc Thai. 2000; 83: 1402-1409
        • Kakita Y.
        • Oshiro K.
        • O'Briain D.S.
        • et al.
        Selective demonstration of mural nerves in ganglionic and aganglionic colon by immunohistochemistry for glucose transporter-1: prominent extrinsic nerve pattern staining in Hirschsprung disease.
        Arch Pathol Lab Med. 2000; 124: 1314-1319
        • Ratcliffe E.M.
        • deSa D.J.
        • Dixon M.F.
        • et al.
        Choline acetyltransferase (ChAT) immunoreactivity in paraffin sections of normal and diseased intestines.
        J Histochem Cytochem. 1998; 46: 1223-1231
        • Kobayashi H.
        • Hirakawa H.
        • O'Briain D.S.
        • et al.
        Nerve growth factor receptor staining of suction biopsies in the diagnosis of Hirschsprung's disease.
        J Pediatr Surg. 1994; 29: 1224-1227
        • Romanska H.M.
        • Bishop A.E.
        • Brereton R.J.
        • et al.
        Immunocytochemistry for neuronal markers shows deficiencies in conventional histology in the treatment of Hirschsprung's disease.
        J Pediatr Surg. 1993; 28: 1059-1062
        • Sarnat H.B.
        • Seagram G.F.
        • Trevenen C.L.
        • et al.
        A fluorochromic stain for nucleic acids to demonstrate submucosal and myenteric neurons in Hirschsprung's disease.
        Am J Clin Pathol. 1985; 83: 722-725
        • Meier-Ruge W.A.
        • Bruder E.
        Pathology of chronic constipation in pediatric and adult coloproctology.
        Karger, Basel2005