Visualization of the human enteric nervous system by confocal laser endomicroscopy in Hirschsprung's disease: An alternative to intraoperative histopathological diagnosis?

• Published in: Neurogastroenterology and motility Vol. 32; no. 5; pp. e13805 - n/a
• Main Authors: Shimojima, Naoki, Kobayashi, Masakuni, Kamba, Shunsuke, Harada, Atsushi, Hirobe, Seiichi, Ieiri, Satoshi, Kuroda, Tatsuo, Sumiyama, Kazuki
• Format: Journal Article
• Language: English
• Published: England Wiley Subscription Services, Inc 01.05.2020
• Subjects: Colon; confocal laser endomicroscopy; Constipation; Diagnosis; Digestive System Surgical Procedures - methods; Endoscopy; Enteric nervous system; Enteric Nervous System - diagnostic imaging; Enteric Nervous System - pathology; Feasibility studies; Female; Ganglion cells; Hirschsprung Disease - diagnostic imaging; Hirschsprung Disease - pathology; Hirschsprung Disease - surgery; Hirschsprung's disease; Humans; Infant; Infant, Newborn; intraoperative frozen section; Male; Microscopy, Confocal - methods; Monitoring, Intraoperative - methods; Nervous system; Patients; Surgery; transition zone; Hirschsprung's disease; confocal laser endomicroscopy; enteric nervous system; intraoperative frozen section; transition zone
• ISSN: 1350-1925; 1365-2982; 1365-2982
• DOI: 10.1111/nmo.13805

Background Hirschsprung's disease is a congenital abnormality of the enteric nervous system (ENS) presenting severe constipation soon after birth due to the lack of ganglion cells in the distal gut. Surgery for Hirschsprung's disease requires an intraoperative histopathological diagnosis to assess the extent of aganglionosis. Confocal laser endomicroscopy (CLE) is a novel endoscopic technique allowing real‐time, in vivo analysis of cellular details during ongoing endoscopy. In this study, we evaluated the possibility of a new application of CLE to provide real‐time observations of the ENS in patients with Hirschsprung's disease. In this preclinical feasibility study, we assessed the visualization of the ENS by CLE using surgically resected intestines. Methods The subjects were nine patients who underwent pull‐through surgery for Hirschsprung's disease between September 2014 and March 2016. The colon specimens were stained with 0.1% cresyl violet and evaluated using CLE. We compared the CLE findings with those of the histopathological examination. Key Results The ENS was clearly visualized as a ladder‐like structure in the ganglionic segment but was not observed in the aganglionic segment. Of the 69 samples, corresponding positive and negative results for both CLE and the histopathology were obtained in 61 (88%). In addition, CLE was able to visualize unique, wavy structures comprising thick nerve bundles characteristic of the aganglionic/transition zone in Hirschsprung's disease. Conclusions and Inferences As a novel tool for visualizing the human ENS, CLE has the potential to revolutionize how pediatric surgeons identify the level of ganglionosis during surgery for Hirschsprung's disease and may be a superior alternative to intraoperative histopathological diagnosis. (Center) Illustration showing intestines, including normal, transitional, and aganglionic segments in Hirschsprung’s disease. Sixty‐nine samples from nine patients with Hirschsprung’s disease were evaluated by confocal laser endomicroscopy (CLE) (left) and hematoxylin‐eosin (H & E) staining (right). The detection rate for the enteric nervous system (ENS) was 100% in the normal segments and 63% in the transition zones. The concordance of the positive and negative ENS visualizations for CLE and the histopathological findings were 88.4%.