Transanal endorectal vs. Duhamel pull-through for Hirschsprung's disease.

INTRODUCTION: The aim of this study was to test the hypothesis that the early functional outcome for patients with rectosigmoid Hirschsprung's disease (HD) is comparable for the Duhamel pull-through procedure and the transanal endorectal pull-through (TERPT) procedure, with less discomfort for the patient postoperatively after the TERPT technique. MATERIAL AND METHODS: Eleven patients operated on with the TERPT technique (T Group) were prospectively registered and compared retrospectively with 18 patients operated on with the Duhamel pull-through (D Group). Data recorded included patient demographics, operative treatment, complications, hospital stay and bowel functions. The follow-up time was limited to 24 months. RESULTS: The T Group started oral feeding sooner, their bowel movements started sooner and they had less need for analgesia postoperatively and a significantly shorter hospital stay. 71% of the patients in the D Group needed re-intervention compared to only 18% of the T Group. Enterocolitis was seen in two patients in both groups. At the last clinical control ten patients had constipation (59%) and three had soiling (18%) in the D Group. Three patients in the T Group had constipation (27%) and one had soiling (9%). CONCLUSION: Our results support the use of the TERPT method rather than the Duhamel pull-through for rectosigmoid HD.

CART-peptide immunoreactivity in enteric nerves in patients with Hirschsprung's disease.

AIMS: Cocaine- and amphetamine-regulated transcript (CART)-peptide is found in the brain and participates in the control of feeding behavior. It is also expressed in the peripheral nervous system and is suggested to have neuromodulatory and/or neurotrophic effects in rat intestine. The aims of this study were to investigate the presence of CART-peptide in the normal ganglionic as well as aganglionic intestine from patients with Hirschsprung's disease and the peptide's possible coexistence with other neurotransmitters. METHODS: Intestinal specimens from nine patients with Hirschsprung's disease were examined using immunohistochemistry. A double immunostaining technique was used in order to elucidate the presence of CART-peptide in NOS and VIP-containing enteric neurons. RESULTS: In ganglionic intestine, CART-peptide was found in numerous nerve fibers, predominantly within the smooth muscle layers and in myenteric nerve cell bodies. A high degree of co-localization of CART with NOS and VIP was seen. Only very few CART immunoreactive nerve fibers and no nerve cell bodies were found in the aganglionic intestine. CONCLUSIONS: This is the first report on the presence of CART-peptide in the human intestine. In the ganglionic intestine CART was detected mainly in myenteric neurons, while only very few CART-IR nerve fibers were found in the aganglionic intestine. This, together with the coexistence of CART with NOS and VIP, indicates an intrinsic origin of the CART-containing neurons and suggests that CART may influence NO and VIP-induced effects.

Trichobezoar in a child with concomitant coeliac disease: a case report.

UNLABELLED: We report on a case of childhood coeliac disease presenting with tricophagia and trichobezoar. The combination of obstructive symptoms, severe hypoalbuminaemia and a large abdominal mass detected on CT scan warranted diagnostic gastroscopy and laparotomy, resulting in removal of a large gastric trichobezoar. Surgical recovery was uneventful although serologic studies for coeliac disease were abnormal. Coeliac disease was confirmed by subsequent biopsy. CONCLUSION: Concomitant trichobezoar and coeliac disease in a child is reported for the first time. It is postulated that the trichobezoar was a result of coeliac disease-induced pica.

Survival of neurons and interstitial cells of Cajal after autotransplantation of myenteric ganglia from small intestine in the lethal spotted mouse.

To avoid mutilating surgery in the treatment of distal aganglionosis, transplantation of autologous nervous elements to the affected intestine would be an attractive option. This treatment modality has emerged as a possible alternative for different brain disorders, mostly using fetal nervous tissue. Our objective was to evaluate whether myenteric ganglia (MG) and interstitial cells of Cajal (ICC) could survive a transplantation procedure and to evaluate possible differences between animals with distal colonic aganglionosis (lethal spotted mice) and their healthy littermates. Autologous transplantation of MG with adherent smooth muscle from small intestine to the subcapsular space of the kidney was performed in mice 3-12 weeks of age. The transplants were evaluated 5 to 9 days postoperatively. The presence of myenteric neurons in the transplants was registered using immunohistochemical detection of different neurotransmitters and markers. For identification of ICC antibodies against c-kit, a cell surface tyrosine-kinase receptor, were used. The transplants showed overall good survival. Neurons containing the general neuronal marker protein gene-related product, the neuronal nitric oxide synthesizing enzyme, and the neuropeptides vasoactive intestinal peptide, pituitary adenylate cyclase-activating peptide, calcitonin gene-related peptide, galanin, substance P, and neuropeptide Y could be shown throughout the transplants. ICC were consistently seen in the grafted tissue among the smooth muscle cells, particularly in the deep muscular plexus, and within the MG. No obvious differences in ICC or enteric neuronal tissue survival, or in the frequency of the various neuronal populations displayed could be detected between the two groups of animals. These findings support the use of autologous MG for further research on transplantation of enteric ganglia as a possible alternative treatment for colonic aganglionosis.

Ulceration in an ileocolic anastomosis treated with ranitidin.

The authors report the case of a child born with a gastroschisis and an ileal atresia. After surgery, only 100 cm small bowel and the distal one third of his colon remained. Perianastomotic ulcers developed 6 years later. These were treated successfully with ranitidin, a treatment not previously reported in the literature. The authors conclude that treatment with ranitidin was successful in a patient with an ulcer in an ileocolic anastomosis.

Complications of laparoscopy-aided gastrostomies in pediatric practice.

PURPOSE: The aim of this report is to establish the frequency and type of complications of laparoscopy-aided gastrostomy in pediatric practice and to identify patients at risk for postoperative complications. METHOD: This is a follow-up study of 98 children with nutritional problems including inability to swallow, inadequate calorie intake in neurologically impaired children, patients with cystic fibrosis, malignancies, neurometabolic diseases, and cardiac malformations. Laparoscopy-aided gastrostomy was attempted in all patients. These patients have undergone follow-up at our outpatient clinic. Postoperative complications and problems with the gastrostomy device were registered. The postoperative complications were divided into minor problems and major or life-threatening complications. RESULTS: There was no perioperative mortality. No life-threatening complication developed, whereas minor problems were common, necessitating medical attention postoperatively. Patients with congenital heart disease, chronic respiratory failure, and metabolic diseases experienced the highest frequency of postoperative complications. CONCLUSIONS: The surgical placement of an enteral access device in children should be considered a major surgical procedure, demanding medical attention for 1 to 2 months postoperatively. The rate and severity of complications with the method described are tolerable considering the severity of the underlying diseases.

Gastrostomy button causing perforation of the posterior gastric wall.

A gastrostomy button complication, not previously reported, is described. The button, with an inflatable balloon, was used for nutrition. The patient had had a gastrostomy for 4.5 y, with the same type of gastrostomy button for the previous 2 y and the same device for 1 y. The tip of the button caused a perforation of the posterior stomach wall, leading to death.

Functional and morphological examination of ganglionic and aganglionic distal gut from the lethal spotted mouse.

The aim of the study was to evaluate both morphologically and functionally the distal large intestine from the aganglionic lethal spotted (ls/ls) mutant mouse and their healthy litter mates. Immunohistochemically, the aganglionic murine distal large intestine showed an absence of nerve cell bodies, and a reduction or absence of nerve fibers displaying immunoreactivity (IR) for protein gene product (PGP), nitric oxide synthase (NOS), vasoactive intestinal peptide (VIP), substance P (SP), galanin and calcitonin gene-related peptide (CGRP), while in the ganglionic large intestine these neuronal populations were abundantly present throughout the gut wall. Pathological nerve trunks within the afflicted intestinal segment were found to harbour PGP- and neuropeptide Y (NPY)-IR nerve fibers. Smooth muscle specimens from the distal part of the murine distal large intestine were mounted as ring preparations in vitro and subjected to electrical field stimulation (EFS). EFS (4-20 Hz) caused a contraction in both ganglionic and aganglionic intestine. After pretreatment with atropine EFS (20 Hz) evoked a biphasic motor response, a relaxation followed by a contraction in control specimens, while no motor response was seen in aganglionic intestine. Addition of the NOS-inhibitor N-nitro-L-arginine methyl ester (L-NAME) caused per se a weak and transient contraction and reduced the amplitude of the EFS-induced relaxation in control intestine.

Laparoscopy aided gastrostomy in children.

BACKGROUND AND AIMS: The aim of this report is to describe a method for laparoscopy aided button gastrostomy in children. MATERIAL AND METHODS: The method includes the use of two ports, one umbilical and one subcostal on the left side. The stomach is exteriorized using a grasping forceps in the subcostal port. Under direct vision the gastrostomy button, MIC-KEY, is inserted into the stomach at the lesser curvature and secured by purse string sutures. The stomach is attached to the anterior abdominal wall. RESULTS: The results show that this method has been successfully used in 33 children without operative complications. CONCLUSIONS: We conclude that by inserting the gastrostomy button under direct vision, damage to other abdominal organs is avoided and a correct placement at the lesser curvature obtained. The combination of laparoscopic and open procedures makes the method easy and safe.

Frequency of RET mutations in long- and short-segment Hirschsprung disease.

Hirschsprung disease, or congenital aganglionic megacolon, is a genetic disorder of neural crest development affecting 1:5,000 newborns. Mutations in the RET proto-oncogene, repeatedly identified in the heterozygous state in both long- and short-segment Hirschsprung patients, lead to loss of both transforming and differentiating capacities of the activated RET through a dominant negative effect when expressed in appropriate cellular systems. The approach of single-strand conformational polymorphism analysis established for all the 20 exons of the RET proto-oncogene, and previously used to screen for point mutations in Hirschsprung patients allowed us to identify seven additional mutations among 39 sporadic and familial cases of Hirschsprung disease (detection rate 18%). This relatively low efficiency in detecting mutations of RET in Hirschsprung patients cannot be accounted by the hypothesis of genetic heterogeneity, which is not supported by the results of linkage analysis in the pedigrees analyzed so far. Almost 74% of the point mutations in our series, as well as in other patient series, were identified among long segment patients, who represented only 25% of our patient population. The finding of a C620R substitution in a patient affected with total colonic aganglionosis confirms the involvement of this mutation in the pathogenesis of different phenotypes (i.e., medullary thyroid carcinoma and Hirschsprung). Finally the R313Q mutation identified for the first time in homozygosity in a child born of consanguineous parents is associated with the most severe Hirschsprung phenotype (total colonic aganglionosis with small bowel involvement).

Lack of neuronal nitric oxide synthase in nerve fibers of aganglionic intestine: a clue to Hirschsprung's disease.

The lack of nonadrenergic, noncholinergic (NANC) inhibitory innervation in aganglionic intestine is typical of Hirschsprung's disease. Several neuropeptides participating in the intestinal NANC innervation are greatly reduced in aganglionic intestine. However, these findings do not fully explain the pathophysiology of the disease. Recently, nitric oxide (NO) has been presented as a potent smooth muscle relaxant, and the enzyme responsible for its formation, nitric oxide synthase (NOS) has been demonstrated in neuronal elements in both the central and peripheral nervous system. In our study, nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase staining, a marker for NOS, and NOS immunohistochemistry revealed a dense innervation of the smooth muscle layers and the myenteric ganglia in ganglionic non afflicted intestine from patients with Hirschsprung's disease. By contrast, there was an almost complete lack of NOS-immunoreactive and NADPH-diaphorase-positive nerve fibers in the afflicted aganglionic bowel. NOS and vasoactive intestinal peptide were found to be partially colocalized in nerve fibers and neuronal cell bodies in the ganglionic but not in the aganglionic intestine. The lack of NO-producing nerve fibers in the aganglionic intestine probably contributes to the inability of the smooth muscle to relax, thereby causing lack of peristalsis in Hirschsprung's disease.

Chromogranin A and B in neuronal elements in Hirschsprung's disease: an immunocytochemical and radioimmunoassay study.

Chromogranin A and B (CAB) occur in several peptide hormone-producing cells and in neurons of the brain. The aim of the present study was to investigate the possible neuronal localization of these chromogranins in the ganglionic and aganglionic bowel in Hirschsprung's disease by immunocytochemistry and radioimmunoassay, using antibodies recognizing either chromogranin A or both chromogranin A and B. Further, the coexistence of chromogranins and other neuronal constituents was studied. CAB were found in nerve fibers and occasionally in nerve cell bodies of submucous and myenteric ganglia in the ganglionic bowel, indicating that at least a population of chromogranin-immunoreactive nerve fibers is intrinsic in origin. CAB-immunoreactive fibers were numerous in the muscle layers of the aganglionic segment. These fibers contained tyrosine hydroxylase (TH), which indicates that they are adrenergic, in both ganglionic and aganglionic bowel. In the muscle layers of aganglionic (but not ganglionic) bowel, chromogranin A coexisted with galanin, neuropeptide Y (NPY), and vasoactive intestinal peptide (VIP). The concentration of CAB in smooth muscle specimens was higher in the aganglionic bowel than in the ganglionic bowel. Thus, chromogranins are present in the human enteric gut hyperinnervating the aganglionic bowel of Hirschsprung's disease.

Hirschsprung's disease--immunohistochemical findings.

Hirschsprung's disease (HSCR) is characterized by a non-propulsive distal intestinal segment (usually colon) leading to a functional obstruction. An absence of ganglia in the affected segment explains the synonymous term "aganglionosis coli". The lack of peristalsis is partly due to a deficient intestinal smooth muscle relaxation based on an absence of non-adrenergic, non-cholinergic (NANC) inhibitory innervation. Morphological studies using conventional microscopy, immunohistochemistry and immunochemistry against general neuronal markers and neuropeptides have been used to characterize the disturbed NANC innervation in HSCR. An increased cholinergic and adrenergic innervation is registered in the aganglionic segment in spite of the lack of neuronal cell bodies: Neuropeptides like vasoactive intestinal peptide (VIP), pituitary adenylate cyclase-activating polypeptide (PACAP), gastrin-releasing peptide (GRP), calcitonin gene-related peptide (CGRP), substance P (SP), enkephalins and galanin immunoreactive nerve fibres are all reduced in number in the aganglionic segment. In contrast, neuropeptide Y (NPY)-containing nerve fibres are increased in number in the diseased segment, probably reflecting the adrenergic hyperinnervation. General neuronal markers including chromogranins have been used to map the neuronal network in the HSCR intestine and also to investigate the endocrine cell system in the intestinal mucosa. Nitric oxide is a potent component of the NANC inhibitory innervation and its synthesizing enzyme, nitric oxide synthase (NOS), is shown to be almost absent in the neuronal system in aganglionic intestine.

Peptide-containing neurons remain unaffected after intestinal autotransplantation: an experimental study in the piglet.

The gut is richly supplied with peptide-containing nervous elements. In the present immunocytochemical study the origin, occurrence and topographical distribution of nerves containing vasoactive intestinal polypeptide (VIP), enkephalin, substance P (SP), somatostatin, neuropeptide Y (NPY), calcitonin gene-related peptide (CGRP), gastrin-releasing peptide (GRP) and galanin were investigated in the porcine small intestine. In order to study the origin (extrinsic or intrinsic) of the nerve fibers, specimens from autotransplanted and extrinsically denervated jejunum were examined. Furthermore, possible changes in the distribution of intrinsic neurons after extrinsic denervation were studied. In the control jejunum each nerve fiber population had its own characteristic topographic distribution. There was no overt difference in distribution pattern of peptide-containing nerve fibers and cell bodies between the transplanted and the control segment except that NPY-, SP- and CGRP-containing nerve fibers disappeared around blood vessels. Thus VIP-, somatostatin-, GRP-, enkephalin- and galanin-containing nerve fibers were visibly unchanged in the transplanted segment. The results support the view that the peptide-containing nerve fibers are mainly intrinsic in origin except the NPY-, SP- or CGRP-containing perivascular nerve fibers which are extrinsic to the gut wall. In addition, the results of the present study suggest that transplantation and extrinsic denervation have no major effect on the distribution pattern of the intrinsic neuronal systems.

A novel neuropeptide, pituitary adenylate cyclase-activating polypeptide (PACAP), in human intestine: evidence for reduced content in Hirschsprung's disease.

A novel neuropeptide, pituitary adenylate cyclase-activating polypeptide (PACAP), exhibits sequence homology with vasoactive intestinal polypeptide (VIP) and occurs in the mammalian brain, lung and gut. The distribution of PACAP in ganglionic and aganglionic portions of the large intestine of patients with Hirschsprung's disease was examined by immunohistochemistry and radioimmunoassay. PACAP-immunoreactive nerve fibers were distributed in all layers of the ganglionic and aganglionic segments of the intestine, although they were less numerous in the latter, and PACAP-immunoreactive nerve cell bodies were seen in the ganglionic portion of the intestine. The concentration of immunoreactive PACAP was lower in the aganglionic than in the ganglionic segment of the intestinal wall. PACAP and VIP were found to coexist in both ganglionic and aganglionic segments of the intestine. Apparently, PACAP participates in the regulation of gut motility. The scarcer PACAP innervation of the aganglionic segment may contribute to the defect in intestinal relaxation seen in patients with Hirschsprung's disease.

Sacrococcygeal teratoma in Sweden between 1978 and 1989: long-term functional results.

Thirty-four patients operated with sacrococcygeal teratoma in Sweden between 1978 and 1989 were reviewed. Twenty-five children were available for functional follow-up. The patients and their parents were interviewed for bowel and micturition habits. Fourteen patients from this number were subjected to anorectal manometry (56%). Fifteen children reported normal bowel habits (60%). In 10 patients (40%) soiling was observed. However, four of them were under 3 years of age and wearing diapers, which made the functional evaluation difficult. The manometries showed normal and resting tone and squeezing pressures in 10 patients and subnormal values in four patients who also had soiling problems. All investigated children showed normal rectoanal inhibition reflex. Twenty-one patients reported normal micturition, in four (16%) urinary incontinence was recorded. Two of the latter children required intermittent clean catheterization, one was on medication and the last one lives without any treatment. No difference in functional outcome was noted between patients with intrapelvic or extrapelvic tumor location. Retrospectively, it is not possible to know whether the observed functional outcome is due to tumor growth or the result of surgery. Preoperative clinical investigation and in some cases anorectal manometry and cystometry could theoretically resolve this problem.

NPY hyperinnervation in Hirschsprung's disease: both adrenergic and nonadrenergic fibers contribute.

In Hirschsprung's disease, the aganglionic bowel is characterized by an absence of ganglion cells and an increased number of adrenergic and presumed cholinergic nerve fibers. In addition, a severe derangement of peptide-containing nerve fibers is encountered including a hyperinnervation of neuropeptide Y (NPY)-containing fibers. Using immunochemical and immunocytochemical methods, we examined the nature of the NPY-containing nerve fibers contributing to the hyperinnervation. The concentration of NPY was markedly increased in the aganglionic segment. Coexistence of NPY, vasoactive intestinal peptide (VIP), and the adrenergic enzyme tyrosine hydroxylase (TH) showed small populations of nerve fibers containing NPY/TH, NPY/VIP, or TH alone in ganglionic intestine. Numerous nerve fibers stored VIP but lacked NPY. These fibers did not contain TH, indicating that all VIP-containing fibers are nonadrenergic. In the aganglionic intestine there was a marked increase in the number of nerve fibers storing NPY/TH and NPY/VIP, whereas the fibers storing VIP alone were reduced in number. A small number of nerve fibers storing NPY alone occurred in the hypertrophic nerve bundles. NPY/VIP-containing nerve fibers were particularly numerous in the mucosa in aganglionic intestine, which may be of interest in the diagnosis of Hirschsprung's disease allowing the use of mucosal biopsy specimens. Thus, the proliferating NPY-containing nerve fibers in the aganglionic intestine seem to comprise three different populations, one adrenergic and two nonadrenergic, one of which contains in addition VIP.