Surgical Techniques for the Treatment of Hirschsprung's Disease—A Historical Systematic Review and Current Status Quo

Introduction and purpose: Hirschsprung's disease, also known as congenital aganglionic megacolon, is a rare congenital disorder that affects the large intestine. Due to the absence of ganglion cells, the affected segment of the colon becomes narrow and unable to relax. The disease is present from birth but may not always be immediately apparent. In this paper, we will attempt to present the current state of knowledge regarding the diagnosis and treatment of Hirschsprung's disease, based on the analysis of literature available on the PubMed platform. Description of the state of knowledge: Hirschsprung's disease (HSCR), also known as congenital aganglionosis of the colon, involves abnormal migration, proliferation, and differentiation of neural crest cells, leading to the absence of autonomic nerve ganglia within the colon. HSCR is associated with mutations in several genes, with RET, GDNF, EDNRB and SOX10 being identified as the main causes of the disease. Mutations in the RET gene are associated with the hereditary form of Hirschsprung's disease. Symptoms of HSCR appear in newborns and may include bilious vomiting, diarrhea associated with enterocolitis, failure to pass meconium within the first 24 hours of life, impaired peristalsis, jaundice, feeding difficulties, and progressive abdominal distension. Summary: Diagnosis is typically made based on clinical presentation, imaging studies, and biopsy. Treatment usually involves surgery to remove the affected segment of the colon and reconnect the healthy portions. Although postoperative complications are relatively common, long-term studies suggest that the majority of children with Hirschsprung's disease function well in society.

Hirschsprung's disease (HSCR) is a common congenital gut motility disorder characterized by the reduction or absence of enteric neurons in the distal region of the colon. The Dominant megacolon (Dom) mutant mouse, which carries a spontaneous mutation in Sox10, exhibits HSCR‐like phenotypes, and hence has been used as an animal model of HSCR. It has been known that in Sox10Dom/+ mouse embryos, the migration and differentiation of neural crest cells (NCCs), which are progenitors of enteric neurons and glial cells, are abnormal, leading to hypoganglionosis or aganglionosis in the hindgut. In Sox10Dom/Dom homozygous embryos, the entire gut tube is aganglionic and the embryo dies before E13.5. However, it is still unknown whether hypoganglionic and aganglionic phenotypes exhibited by Dom mice is a result of abnormalities in NCCs only (cell‐autonomous effects), alterations of gut microenvironment through which NCCs migrate (niche effects), or both. Previously, an organotypic gut explant system has already been established, which allows ex vivo co‐culture of donor NCCs of different genotypes with a recipient embryonic gut segment isolated from embryos of the same or other genotypes. In the present study, E13.5 Dom mouse hindgut explants were used as recipient gut segments for transplantation of donor NCCs. Five days after cell transplantation, the hindgut explant cultured ex vivo appeared morphologically and histologically normal with rhythmic contractions and relaxations, indicating that the development of the hindgut explant ex vivo was similar to that in vivo. To obtain donor enteric neural crest cells (ENCCs), midgut segments which were genetically labeled with GFP were dissected from E11.5 mouse embryos and cultured on a fibronectin‐coated surface. ENCCs emigrated from the midgut segments were collected and transplanted to the hindgut explant, which was then cultured ex vivo for 5 days. We found that transplanted ENCCs survived, migrated, and differentiated into TuJ1‐immunoreative enteric neurons in normoganglionic and hypoganglionic segments of the hindgut explant. When transplanted to aganglionic segments of the hindgut, ENCCs were still able to differentiate into TuJ1‐immunoreactive neurons, but they were not able to migrate as far as those transplanted cells in the normoganglionic and hypoganglionic segments, and most of them stayed near the transplantation site without forming a normal neuronal network. Our results indicated that endogenous enteric neurons were required for the normal migration and integration of transplanted ENCCs within the hindgut explant.Support or Funding InformationThe work was supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project No.: CUHK 14175017).This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Ondine's curse associated with Hirschsprung disease and ganglioneuroblastoma.

Noncompaction cardiomyopathy in Hirschsprung's disease: a case report.

Hirschsprung's disease (HSCR), a birth defect characterized by variable aganglionosis of the gut, affects about 1 in 5000 births and is a consequence of abnormal development of neural crest cells, from which enteric ganglia derive. In the companion article in this issue (Shen etal., Neurogasterenterol Motil 28: 266-73), the authors search for long non-coding RNAs (lncRNAs) differentially expressed in bowel tissues of infants with HSCR. Microarray analysis of over 37000 lncRNAs and 34000 mRNAs was done. The key result was identification of a set of 5 lncRNAs that is a potential diagnostic biomarker of HSCR. In this minireview, I provide an overview of neural crest development and the gene regulatory networks involved in specification, epithelial-mesenchymal transition, and migration of neural crest cells. Genes involved in later development, proliferation, and differentiation of neural crest cells as they migrate into the gut are also reviewed. Many of these genes are associated with HSCR, including RET, GDNF, GFRα, EDN3, and EDNRB. LncRNAs and their roles in development and disease and their use as biomarkers are discussed. The authors of the companion article previously used a multipronged approach to elucidate the etiology of HSCR by examining the effects of specific miRNAs or lncRNAs and target genes on cell migration, proliferation, cell cycle, and apoptosis invitro. These studies are discussed in terms of their elegance and limitations. The companion article identifies many new lncRNAs that, in addition to providing potential biomarkers of HSCR, may be a treasure trove for future investigations.

The enteric nervous system regulates the functions of the gastrointestinal system, which include food transportation, digestion, nutrient and liquid absorption and expulsion of waste. The enteric nervous system is comprised of neurons and glia that are primarily derived from a multipotent, migratory population of cells called neural crest cells. Defects in the formation, migration and or differentiation of neural crest cells can lead to incomplete colonization of the gastrointestinal tract and perturbed ENS development resulting in Hirschsprung disease. Hirschsprung disease is a congenital disorder characterized by the absence of ganglia in variable regions of the gastrointestinal tract and ~50% of the known cases of Hirschsprung disease have an unknown genetic diagnosis. This makes it imperative to identify other genes and biological processes that contribute to the etiology and pathogenesis of Hirschsprung disease. We have identified three new genes, Tcof1, Polr1a and Polr1c, and the process of rDNA transcription which is a rate‐limiting step in ribosome biogenesis, as novel regulators of neural crest cell development, enteric nervous system formation and the etiology of Hirschsprung disease. Loss of function mutation of Tcof1, Polr1a and Polr1c in neural crest cells results in total intestinal aganglionosis, the most severe form of Hirschsprung disease in mice. Mechanistically, downregulation of Tcof1, Polr1a and Polr1c results in reduced rRNA synthesis, which leads to increased p53‐dependent NCC apoptosis, and insufficient NCC to colonize the gut. This led us to hypothesize that inhibition of p53 could rescue the Hirschsprung phenotype in the mutants, and we are currently testing this and other and other approaches as potential preventative therapies.

The pathogenesis of Hirschsprung's disease (HSCR) is complex. Recently, it has been found that histone modifications can alter genetic susceptibility and play important roles in the proliferation, differentiation and migration of neural crest cells. H3K36 methylation plays a significant role in gene transcriptional activation and expression, but its pathogenic mechanism in HSCR has not yet been studied. This study aimed to elucidate its role and molecular mechanism in HSCR. Western blot analysis, immunohistochemistry (IHC) and reverse transcription-quantitative PCR (RT‒qPCR) were used to investigate H3K36 methylation and methyltransferase levels in dilated and stenotic colon tissue sections from children with. We confirm that SMYD2 is the primary cause of differential H3K36 methylation and influences cell proliferation and migration in HSCR. Subsequently, quantitative detection of m6A RNA methylation revealed that SMYD2 can alter m6A methylation levels. Western blot analysis, RT-qPCR, co-immunoprecipitation (co-IP), and immunofluorescence colocalization were utilized to confirm that SMYD2 can regulate METTL3 expression and affect m6A methylation, affecting cell proliferation and migration. These results confirm that the H3K36 methyltransferase SMYD2 can affect cell proliferation and migration in Hirschsprung's disease by regulating METTL3. Our study suggested that H3K36 methylation plays an important role in HSCR, confirming that the methyltransferase SMYD2 can affect m6A methylation levels and intestinal nervous system development by regulating METTL3 expression.

Hirschsprung disease (HSCR) is a human congenital disorder, defined by the absence of ganglia from variable lengths of the colon. These ganglia comprise the enteric nervous system (ENS) and are derived from migratory neural crest cells (NCCs). The inheritance of HSCR is complex, often non-Mendelian and characterized by variable penetrance. Although extensive research has identified many key players in the pathogenesis of Hirschsprung disease, a large number of cases remain genetically undefined. Therefore, additional unidentified genes or modifiers must contribute to the etiology and pathogenesis of Hirschsprung disease. We have discovered that Tcof1 may be one such modifier. Haploinsufficiency of Tcof1 in mice results in a reduction of vagal NCCs and their delayed migration along the length of the gut during early development. This alone, however, is not sufficient to cause colonic aganglionosis as alterations in the balance of NCC proliferation and differentiation ensures NCC colonize the entire length of the gut of Tcof1(+/-) mice by E18.5. In contrast, Tcof1 haploinsufficiency is able to sensitize Pax3(+/-) mice to colonic aganglionosis. Although, Pax3 heterozygous mice do not show ENS defects, compound Pax3;Tcof1 heterozygous mice exhibit cumulative apoptosis which severely reduces the NCC population that migrates into the foregut. In addition, the proliferative capacity of these NCC is also diminished. Taken together with the opposing effects of Pax3 and Tcof1 on NCC differentiation, the synergistic haploinsufficiency of Tcof1 and Pax3 results in colonic aganglionosis in mice and may contribute to the pathogenesis of Hirschsprung disease.

Hirschsprung disease (HD) manifests as a developmental anomaly affecting the enteric nervous system, where there is an absence of ganglion cells in the lower part of the intestine. This deficiency leads to functional blockages within the intestines. HD is usually confirmed or ruled out through rectal biopsy. The identification of any ganglion cells through hematoxylin and eosin (H&E) staining rules out HD. If ganglion cells are absent, further staining with acetylcholine-esterase (AChE) histochemistry or calretinin immunohistochemistry (IHC) forms part of the standard procedure for determining a diagnosis of HD. In 2017, our Institute of Pathology at University Hospital of Heidelberg changed our HD diagnostic procedure from AChE histochemistry to calretinin IHC. In this paper, we report the impact of the diagnostic procedure change on surgical HD therapy procedures and on the clinical outcome of HD patients. We conducted a retrospective review of the diagnostic procedures, clinical data, and postoperative progress of 29 patients who underwent surgical treatment for HD in the Department of Pediatric Surgery, University of Heidelberg, between 2012 and 2021. The patient sample was divided into two groups, each covering a treatment period of 5 years. In 2012-2016, HD diagnosis was performed exclusively using AChE histochemistry (AChE group, n = 17). In 2017-2021, HD diagnosis was performed exclusively using calretinin IHC (CR group, n = 12). There were no significant differences between the groups in sex distribution, weeks of gestation, birth weight, length of the aganglionic segment, or associated congenital anomalies. Almost half of the children in the AChE group, twice as many as in the CR group, required an enterostomy before transanal endorectal pull-through procedure (TERPT). In the AChE group, 4 patients (23.5%) required repeat bowel sampling to confirm the diagnosis. Compared to the AChE group, more children in the CR group suffered from constipation post TERPT. Elevated AChE expression is linked to hypertrophied extrinsic cholinergic nerve fibers in the aganglionic segment in the majority of patients with HD. The manifestation of increased AChE expression develops over time. Therefore, in neonatal patients with HD, especially those in the first 3 weeks of life, an increase in AChE reaction is not detected. Calretinin IHC reliably identifies the presence or absence of ganglion cells and offers multiple benefits over AChE histochemistry. These include the ability to perform the test on paraffin-embedded tissue sections, a straightforward staining pattern, a clear binary interpretation (negative or positive), cost-effectiveness, and utility regardless of patient age. The ability of calretinin IHC to diagnose HD early and time-independently prevented repeated intestinal biopsies in our patient population and allowed us to perform a one-stage TERPT in the first months of life, reducing the number of enterostomies and restoring colonic continuity early. Patients undergoing transanal pull-through under the age of 3 months require a close follow-up to detect cases with bowel movement problems.

Medullary Thyroid Cancer in a Patient with Hirschsprung Disease with a C609Y Germline RET-mutation

Multifocal ganglioneuroblastoma coexistent with total colonic aganglionosis

Non-syndromic Hirschsprung's disease as a result of a RETgene variant.

Objective To evaluate the short-term clinical outcomes of transanal endorectal pull-through colorectal resection and oblique anastomosis for Hirschsprung's disease and Hirschsprung's disease allied disorders.Methods Fifty five patients,who were diagnosed with Hirschsprung's disease and Hirschsprung's disease allied disorders,were recruited in this study.All of them underwent transanal endorectal pull-through colorectal resection to remove the abnormal bowel,and oblique anastomosis to restore the continuity of the bowel.They were followed up after being discharged from the hospital.Their clinical data including operation duration,intraoperative blood loss,length of hospital stay,and defecation function after surgery were retrospectively analyzed.Results No death and postoperative complications were noted in this study.The operation duration and intraoperative blood loss were 70.30 min and 12.5 ml in the patients younger than 3 months,77.95 min and 16 ml in the patients aged 3 months to 1 year,77.26 min and 20 ml in the patients aged 1-3 years,and 122.8 min and 40 ml in the patients older than 3 years.No patients were applied analgesics after surgery.After surgery,the patients had loose stool 4 to 10 times every day in the first 2 days.And most of them had semisolid stool 2-5 times per day after 1 week.No postoperative infection,anastomotic fistula,and anastomosis rupture was observed on these patients.Average length of hospital stay was 1 week.Thirty nine patients were fully recovered from the surgery and followed up for 2-30 months.They all had normal urination function.None of them had obstructed defecation,fecal incontinence and anal stricture.Of the 39 patients,35 male patients had normal erectile function.Thirty eight were younger than 3 years old,and defecated normally 2 months after surgery.The patients younger than 1 year defecated 2-4 times a day.The patients aged 1-3 years old defecated 1-2 times a day.And the patients older than 3 years defected 1-2 times a day.One patient was 7 years and 6 months old,and defecated normally 6 months after surgery.Three patients had enterocolitis around 2 months after surgery,and were cured after conservative treatment.Twenty patients underwent anorectal manometry.And 4 of them had anorectal? inhibitory reflex.Conclusions The short-term clinical outcomes of transanal endorectal pull-through colorectal resection and oblique anastomosis for Hirschsprung's disease and Hirschsprung's disease allied disorders are satisfied. Key words: Hirschsprung' s disease; Proctocolectomy, restorative; Surgical procedures, minimally invasive

A recall-optimised machine learning framework for small data improves risk stratification for Hirschsprung's disease

Failure of enteric neural crest-derived cells (ENCCs) to correctly colonize the embryonic gut results in Hirschsprung's disease (HD). Embryonic stem cells (ESCs) have the potential to differentiate into all tissue-specific cells and lineages, including ENCCs. We investigated the cellular differentiation of ESCs from Sox10-Venus+ mice into both control and endothelin receptor-B knockout (Ednrb KO) mouse gut to assess each region. We established ESCs from Sox10-Venus + mice. These cells were cultured for 2days, then selected and co-cultured with either a dissociated control or Sox10-Venus - Ednrb KO mouse gut (both small intestine and colon) on embryonic day (E) 13.5. Four days later, cells were immunolabeled for Tuj1 and visualized using confocal microscopy. Confocal microscopy revealed that transplanted Sox10-Venu + cells from ESCs migrated extensively within the host gut. Moreover, Tuj1-positive neurites were detected in the transplanted ESCs. Tuj1 expression was significantly decreased in aganglionic HD colon compared to controls (p < 0.05) and the HD small intestine (p < 0.05). This study demonstrated that an appropriate host environment is crucial for normal and complete colonization of the gut. Further investigations are required to confirm whether modifying this environment can improve the results of this model.