A novel Lugol\u2019s iodine staining technique to visualize the upper margin of the surgical anal canal intraoperatively for Hirschsprung disease: a case series

Kazuki Yokota,Wataru Sumida,Toyoki Kudo,Chiyoe Shirota,Akinari Hinoki,Yujiro Tanaka,Hiroo Uchida,Hizuru Amano,Aitaro Takimoto,Takahisa Tainaka,Takeshi Yamamura,Satoshi Makita,Masanao Nakamura,Mitsuhiro Fujishiro

doi:10.1186/s12893-020-00986-3

Kazuki Yokota, Wataru Sumida + Show 12 more

Open Access

https://doi.org/10.1186/s12893-020-00986-3

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Abstract

BackgroundIn cases of Hirschsprung disease, complete and reproducible resection of the aganglionic bowel is ideal to achieve good postoperative bowel function. Reliable identification of the upper margin of the surgical anal canal, which is the squamous-columnar junction, is necessary during transanal pull-through. Here, we describe a novel staining technique using Lugol’s iodine stain to visualize the upper margin of the surgical anal canal.MethodsLugol’s iodine staining was performed in five patients with Hirschsprung disease treated using a single-stage laparoscopic transanal pull-through modified Swenson procedure. In two of these patients, endocytoscopic observation with ultra-high magnification was performed using methylene blue and crystal violet to mark the border of the squamous epithelium at 1 week before surgery. The alignment between the incisional line, which was revealed using Lugol’s iodine staining and endocytoscopic marking, was evaluated. Complications, including postoperative bowel dysfunction, were evaluated.ResultsIn all cases, Lugol’s iodine staining produced a well-demarcated line. The endocytoscopic marking of the upper margin of the surgical anal canal was aligned with the line revealed by Lugol’s iodine staining. There were no complications associated with the transanal pull-through procedure, including postoperative bowel dysfunction.ConclusionsLugol’s iodine staining could be a safe and practical method to visualize the upper margin of the surgical anal canal intraoperatively. This finding may be useful for surgeons to make a consistent removal of the aganglionic bowel during surgery for Hirschsprung disease.

Highlights

In cases of Hirschsprung disease, complete and reproducible resection of the aganglionic bowel is ideal to achieve good postoperative bowel function
The upper margin of the surgical anal canal defines the boundary between the stratified squamous epithelium and simple columnar epithelium, [7] corresponding to the superior margin of the levator ani muscle. [5, 8] To identify this line, we focused on Lugol’s iodine staining, which is a popular technique to stain the normal non-keratinized squamous epithelium used in the diagnosis of esophageal cancer
This study aimed to describe a novel staining technique using Lugol’s iodine stain to visualize the upper margin of the surgical anal canal

Summary

Introduction

In cases of Hirschsprung disease, complete and reproducible resection of the aganglionic bowel is ideal to achieve good postoperative bowel function. We describe a novel staining technique using Lugol’s iodine stain to visualize the upper margin of the surgical anal canal. [5] without establishing a standard method for identifying the upper margin of the surgical anal canal, this boundary is detected intraoperatively through visual inspection or palpation, regardless of the surgeon’s experience. Oono et al reported that Lugol’s iodine staining was useful for identifying a squamous cell carcinoma of the anal canal in situ demarcated as an unstained area with Lugol chromoendoscopy. [9] there are no reports of the use of Lugol’s iodine staining in surgery for HD. Το the best of our knowledge, this is the first case series report, in which Lugol’s iodine staining was used to detect the upper margin of the surgical anal canal during surgery for HD

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