Rectal biopsy: is it really necessary in anorectal malformations?

AIM OF THE STUDY: The coexistence of Hirschsprung's disease (HD) with anorectal malformation (ARM) is rare but many surgeons still ask pathologists to look for ganglia in the terminal rectum or fistula. In this study, we aimed to highlight the rarity of this association and question the necessity of histological evaluation. METHODS: After obtaining board review approval, rectal specimens of ARM patients who underwent corrective surgery in the last 8 years were re-analyzed by two blinded pathologists for the presence and structure of ganglia. Clinical and radiological data of patients retrieved from center records and correlated with histopathologic findings. MAIN RESULTS: 67 patients with ARM were identified, distal rectal specimen was obtained in 47. The median age at the time of surgery was 11 months (2 days-59 months). A normal pattern of ganglia was present in 51.1% (24/47), 29.7% (14/47) had aganglionosis and 19.1% (9/47) were inconclusive due to insufficient material. None of the aganglionic specimens showed other histological findings of HD. Patients were followed up regularly in the outpatient colorectal clinic for a median of 87 months (42-117 m). Only 6 experienced severe constipation (3 ganglionic, 2 no biopsy, 1 aganglionic), all of whom responded to a bowel management program, and none developed other manifestations of HD (abdominal distension, failure to thrive or enterocolitis) or required additional surgery. CONCLUSIONS: Our results strongly suggest that the association of ARM and HD is extremely rare and the practice of searching for ganglia in the distal rectum or fistula of ARM patients should be discouraged to avoid potential misdiagnosis and overtreatment.

Low-Grade Injury following Testicular Torsion: A Multicenter Study Confirming a Disturbing Possibility.

INTRODUCTION: There is an ongoing debate whether to perform orchiectomy or orchidopexy following testicular torsion (TT) in cases where the testis seems non-viable. The main problem is lack of objective criteria defining testicular viability. The aim of this study was to investigate the grade of injury in orchiectomy specimens obtained from cases of TT and its association with clinical findings. METHODS: This multicenter retrospective study involved double-blinded reassessment of the patient files and the pathological specimens using Mikuz classification to analyze the relation between clinical and pathological findings. RESULTS: A total of 289 patient charts from 14 centers were reviewed and 228 were included in this study. Twenty (8.8%) patients had grade 1 injury which refers to reversible injury. The clinical findings of these 20 patients were compared to 208 patients with higher grades of injury. As expected, there was statistically significant difference regarding duration of symptoms (p < 0.001); however, range was wide in both groups (as long as 96 h for grade 1 and as short as 7 h for higher grades). There was no statistically significant difference in any other variable including age (median 14 for both, p = 0.531), symptoms (pain: 19/20 vs. 189/202, p = 0.801; swelling: 13/19 vs. 168/197, p = 0.094), absence of blood flow in Doppler US (15/19 vs. 164/197, p = 0.635), or degree of torsion (median 720° for both, p = 0.172). CONCLUSION: Our study revealed necessity for better criteria to define viability of testis following TT. Histopathological injury appeared to be reversible even in some patients with more severe perioperative findings, late admission, or high degree of twisting. Our findings support the tendency for testicular fixation instead of orchiectomy as none of the clinical or perioperative findings could be attributed to high-grade injury.

Reassessment of a Decade of Experience on Testicular Torsion: Are We Making a Mistake?

INTRODUCTION: Testicular torsion is a serious surgical emergency of children. Prompt recognition and exclusion of other acute scrotal causes are essential for avoiding testicular loss. The aim of this study was to evaluate 10 years of experience with testicular torsion, point out our pitfalls in diagnosis and management, determine our likelihood of performing orchiectomy for potentially reversible injury. MATERIAL AND METHOD: Records of patients operated for testicular torsion in the last decade were reviewed retrospectively. Clinical findings, symptoms, type of surgery, accuracy of radiological evaluation, and the outcome were analyzed. Orchiectomy specimens were reevaluated and histologically graded to determine the existence of previously undetermined low-grade injury. RESULTS: In total, 107 children were operated for testicular torsion. Presentation included pain 96 (89.7%), scrotal swelling 48 (44.8%). Doppler ultrasonography was performed in 96 patients with false-negative results in 26 (27%). Testicular salvage occurred in 65 (60.7%) patients of which 6 (9.2%) developed subsequent testicular atrophy. Forty-two (33.9%) patients were treated with orchiectomy and histologic reevaluation, and grading of the specimens revealed 4 (9.7%) low-grade injury which indicates a potential of reversible injury. Seventeen (13.7%) patients had normal testicular anatomy in surgery. CONCLUSION: Surgical exploration is mandated in case of clinical suspicion for testicular torsion even with a normal flow Doppler ultrasound. Macroscopic evaluation does not always correlate with microscopic findings, and a decision according to it may result in excision of potentially viable testis. Further studies are required to determine the actual risk of contralateral autoimmune damage and increase the rate testicular salvageability after testicular torsion.