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BACKGROUND Suction and capillary pull are 2 biopsy techniques used in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Although these techniques have been shown to perform comparably in terms of overall diagnostic yield, we hypothesized that the capillary pull technique would be associated with improved rapid on-site evaluation (ROSE) adequacy rates thus allowing for a shorter procedure time. METHODS One hundred eighteen patients undergoing EBUS-TBNA for any indication were randomized to suction or capillary pull techniques for the first biopsy pass; the technique used for all subsequent passes was based on operator preference and was not recorded. The first pass was subjected to ROSE and an adequacy assessment was given. ROSE slides were also scored for cellularity of diagnostic/lesional cells and blood contamination. The overall procedure time was also recorded. RESULTS There were no significant differences between suction and capillary pull techniques in terms of ROSE adequacy rates. Cellularity of diagnostic/lesional cells and blood contamination scores were also comparable. There was no significant difference in procedure time for the 2 techniques. CONCLUSION This study suggests no differences in ROSE outcomes between suction and capillary pull techniques in EBUS-TBNA. The technique used should therefore be left to the discretion of the operator.

Introduction Diagnosis of very short-segment Hirschsprung's disease (vsHD) by rectal suction biopsy is challenging as its aganglionic zone (AZ) overlaps with physiologic hypoganglionic zone and calretinin-positive mucosal nerves may extend from the transition zone (TZ) into AZ. We studied whether an increasing trend/gradient of calretinin-positive mucosal nerves along the distance from AZ toward TZ aids in diagnosis of HD. Materials and Methods In this study, 46 rectal suction biopsies from non-HD and HD, and 15 pull-through specimens from short-segment HD were evaluated by mucosal calretinin immunostain (CI) and image processing and analysis (IPA) to measure pixel count (PC, the percentage of calretinin stained pixels in the mucosa). Consecutive longitudinal sections of proximal AZ toward distal TZ in HD pull-through specimens were utilized as a vsHD surrogate model. First, we studied variability of mucosal CI in non-HD biopsies along the distance from dentate line. Second, we determined a cutoff point of mucosal CI by IPA that separated non-HD versus HD and applied this cutoff to longitudinal sections from proximal AZ to distal TZ segments in HD pull-through specimens. Third, we studied whether an increasing trend of mucosal CI was universally observed in HD pull-through. Results Our findings included a significant variability in PC along the biopsy distance in non-HD cases. Positive mucosal CI was found in proximal AZ in 6 (43%) of 14 HD pull-through, among which 1 case lacked submucosal nerve hypertrophy in the proximal AZ. All 14 HD pull-through cases showed an increasing trend/gradient of PC from AZ toward TZ. Conclusion Based on our findings, the presence or absence of mucosal CI positivity and submucosal nerve hypertrophy may not reliably diagnose vsHD in rectal suction biopsy. While we acknowledge that the density of mucosal innervation in variable contexts and anatomical locations is unknown and yet to be explored, our study suggests that an increasing trend of positive mucosal CI from AZ toward TZ by IPA might prove to be a useful tool for the diagnosis of vsHD in the future.

Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing.

BACKGROUND: Male breast cancer is a rare disease, accounting for 0, 1% of all cancers in men and for 0.6% to 1% of all breast cancers. The aim of this paper is to present histopathological and clinical features of male breast cancer at the Clinic for Surgery, Clinical Hospital Centre Rijeka, Croatia, over the 14-year period. METHODS: Between 2003 and 2017 twenty-seven men underwent surgery for breast cancer at our facility. Information retreived from the patients’ records included the stage of the disease, histologic type, histologic grade, hormone receptor status of the primary tumour, and the axillary lymph node status. RESULTS: The majority of patients presented with advanced stages of the disease (stages III and IV). Grade 2 was the most frequent histologic grade. Invasive ductal carcinoma of no special type was the most common histologic type. Hormone receptor status was positive in most of the cases. Approximately half of the patients had positive axillary lymh nodes. CONCLUSIONS: Early diagnosis and treatment are critical to successful treatment of male breast cancer. Due to positive hormone receptors in most of the patients with advanced stages of male breast cancer, hormonal therapy played a critical role. Further research on larger samples will be necessary for developing new methods for diagnosing and treating breast cancer in men.

Objectives: The aim of the study was to evaluate whether anorectal manometry (ARM), which is used to test the rectoanal inhibitory reflex (RAIR), is a safe alternative for reducing the number of invasive rectal suction biopsy (RSB) procedures needed to diagnose Hirschsprung disease (HD).Methods: Between 2010 and 2017, we prospectively collected the ARM results of 105 patients suspected of having HD. Following the outcome, the patients either underwent additional tests to confirm HD or they were treated conservatively. Primary ARM-based diagnoses were compared with the definitive diagnoses based on the pathology reports and/or clinical followups. Additionally, we analyzed whether modifications to our ARM protocol improved diagnostic accuracy.Results: The sensitivity of ARM and RSB was comparable (97% vs 97%). The specificity of ARM, performed according to our initial protocol, was significantly lower than that of RSB. After we modified the protocol the difference between the specificity of ARM and RSB was no longer statistically significant (74% vs 84%, respectively, P = 0.260). The negative predictive value of ARM was 100%, while their positive predictive value was significantly lower than that of RSB (56% vs 97%, P Conclusions: ARM is a viable screening tool for HD and, provided it is performed properly, it can be used to exclude HD with absolute certainty. By contrast, an absent rectoanal inhibitory reflex on ARM should always be followed by an RSB to confirm the diagnosis of HD. Using ARM as the diagnostic of first choice could reduce the number of invasive biopsies.

Gold standard in Hirschsprung disease (HD) diagnosis is rectal suction biopsy (RSB) with hematoxylin and eosin and acetylcholinesterase (ACE) stainings. Sensitivity is 83–93 % and specificity is between 95 and 99 %. The rate of non-conclusive results (NC) due to inadequate samples or variability in the interpretation is about 11–37.8 %. Interpretation is still difficult in neonates. Calretinin (C) is a calcium-binding protein, expressed in the nervous system. It has been introduced as a marker to improve the diagnosis accuracy in HD. We compare sensitivity, specificity between ACE and ACE + C and investigate whether the introduction of C could reduce the rate of inconclusive results. We also tried to define the most adequate age to obtain accurate results from RSB. Data from patients undergoing rectal suction biopsies from 2005 to 2014 was analyzed. Until 2010 we used ACE; since 2011 we used ACE + C. The ROC curve analysis of the NC results regarding the age, showed an optimal cut-off point at 1.5 months (m). It divides the sample into two groups which we compared. We analyzed 91 patients. Results of the RSB: 40 HD (44 %), 34 no Hirschsprung (37.4 %) and 17 NC (18.7 %). Sensitivity = 97.5 %, specificity = 97.1 %, not including the NC (1 false positive, 1 false negative). Results depending on the staining: Results depending on the age: Calretinin decreases the rate of inconclusive results, but not significantly. The percentage of inconclusive results decreases in patients olders than 1.5 m. Further studies are necessary to determine if this technique is useful to improve RSB results in infants younger than 1.5 months.

The diagnosis of Hirschsprung’s disease (HSCR) can be difficult as it relies on histological confirmation of complete absence of enteric ganglion cells in the myenteric and submucosal plexuses of the distal rectum, which extends proximally for varying distances. Today, rectal suction biopsy (RSB) is widely considered to be the gold standard in the diagnostic work-up of patients with suspected HSCR, allowing specimens to be taken safely without general anesthesia on the ward or as an outpatient procedure. However, some histopathologists remain reluctant to confirm the presence or absence of enteric ganglion cells merely on the basis of RSBs, as it necessitates a thick specimen with enough submucosal tissue to be considered as adequate. Consequently, insufficient tissue samples are not uncommon and often result in a diagnostic delay with need for repeat RSB or open rectal biopsy, causing considerable parental anxiety, prolonged hospital stay, and increased costs. Although very rare, serious complications such as rectal bleeding, bowel perforation, and pelvic sepsis have been reported, which in turn add a further risk to the patient. Nevertheless, RSB is a simple, safe, and accurate method for the diagnosis of HSCR.

Background Multiple outbreaks from contaminated duodenoscopes have been reported since 2008. This study assessed results of a multicenter comprehensive quality control (QC) program to enhance manual cleaning efficacy of duodenoscopes in endoscopy units. Methods Digestive Endoscopy Society of Taiwan implemented a QC program with adenosine triphosphate (ATP) testing of patient-used duodenoscopes in 2 rounds of on-site audit in endoscopy units. ATP samples were obtained from 5 different locations of the duodenoscope after manual cleaning. Duodenoscope exceeding ATP benchmark of 200 relative light units indicated inadequate manual cleaning. Results During the first round on-site audit, 12 hospitals and 27 patient-used duodenoscopes were analyzed. Distal end outer surface (29.6%), elevator mechanism (51.9%), distal attachment cap (59.3%), elevator wire channel (37.0%), and suction biopsy channel (37.0%) were inadequately cleaned. Overall, 19 (70.4%) duodenoscopes had inadequate manual cleaning, ranging widely from 0%-100% among endoscopy units. During the follow-up on-site audit, 32 patient-used duodenoscopes were analyzed, and 6 (18.8%) had inadequate manual cleaning. Conclusions ATP tests may provide real-time feedback on the cleaning efficacy of patient-used duodenoscopes. Implementing a comprehensive QC program could enhance the efficacy of manual cleaning in endoscopy units.

INTRODUCTION: The diagnosis of Hirschsprung's disease (HD) relies on the histological demonstration of aganglionosis in the bowel wall. Biopsies may be obtained by rectal suction biopsy (RSB) or by transanal full-thickness excision biopsy (FTB). The objective of the present study was to evaluate the frequency of complications and inconclusive biopsies after FTB in children referred with suspicion of HD. The secondary objective was to calculate the frequency of proven aganglionosis.METHODS: A retrospective chart review was performed of all patients under the age of 16years who underwent transanal FTB during the time period of 2008-2014.RESULTS: A total of 555 patients were included in the review. Inconclusive biopsies were found at the primary biopsy in 35 patients (5.9%). Aganglionosis was found in 12% of the cases. The complication rate was 6.6% (39 patients), 85% of which were classified as a Clavien-Dindo I-II and 15% were classified as Clavien-Dindo III.CONCLUSIONS: In this retrospective evaluation of FTB for the diagnosis of HD, the frequency of inconclusive biopsies at primary attempt was low and the complication rate was relatively high. However, most were minor complications.LEVEL OF EVIDENCE: III.

Aim To present the technique and the diagnostic accuracy of the air test to diagnose Hirschsprung's disease (HD). Materials and methods Children who attended hospital for chronic constipation (CC) between January 2012 and December 2016 for whom the air test was performed were enrolled. The test was conducted during contrast enema under fluoroscopic observation using 20–50 ml injections of air into the rectum through a 10 F Nelaton catheter. The demographics, results of the air test, and additional examinations, as well as the outcomes of subsequent treatments were analysed retrospectively. Results The air test was conducted in 179 patients (median: 3 years, range: 0–14 years), and was positive in 150 and negative in 29 cases. Of the 29 patients with negative results, four were diagnosed with HD by rectal suction biopsy (RSB). Of the remaining 25 patients, RSB was conducted in seven and HD was excluded in all cases. In all 150 patients with positive air test results, CC was adequately controlled with conservative treatment. The sensitivity and specificity of the air test were 100% (4/4) and 85.7% (150/175), respectively. Conclusions The air test can be used as a new non-invasive screening method for HD, performed simultaneously with contrast enema.

Introduction Rectal suction biopsy (RSB) is performed on clinical and radiological suspicion of Hirschsprung disease (HD). Positive histochemical staining for acetylcholinesterase in the lamina propria mucosa and muscularis mucosa together with the absence of ganglion cells in the submucosa confirms HD. A second RSB or a full-thickness biopsy is done in case of doubt. The primary aim of the study was to evaluate the effectiveness of RSB in diagnosing HD. In addition, the results of RSB in preterm born infants were analyzed. Methods This retrospective study included all infants younger than 1 year who had RSB for HD suspicion from January 2004 to April 2014. All histopathological results were reviewed. Sensitivity, specificity, positive, and negative predictive values of the first RSB were calculated. Results In total, 183 patients (99 boys, mean age 11 weeks) were included. HD was diagnosed in 55 patients (30%). A second biopsy was performed in 12/55 patients (22%), which confirmed HD in 9 patients. One patient did not undergo a second biopsy, but HD was excluded based on clinical follow-up. Thus, HD was eventually excluded in 4 of the 55 patients with a positive first RSB. HD was excluded in the first biopsy in 128 patients (70%). In 19 of those (15%), a second biopsy was done, which led to the diagnosis of HD in 10 patients. Two patients with negative biopsy results were still operated on because of the high clinical suspicion for HD, and the histopathological analysis on the operative specimen confirmed HD. Thus, HD was eventually diagnosed in 12 out of 128 patients. Thus, the sensitivity of the first RSB was 81% and the specificity was 97%. The positive predictive value was 93% and the negative predictive value was 91%. A subanalysis for the 38 preterm born infants was done, with a mean conceptional age at the time of biopsy of 44 weeks (range 34–82). Sensitivity and specificity of RSB were 83 and 97%, respectively, with one false-positive and one false-negative results. Conclusion The overall sensitivity of the RSB was 81%, with 12 false-negative results, in which cases extra biopsies had been necessary. The specificity was 97%, with four false-positive findings. We found that RSB can also be reliably and safely performed in preterm born infants, which implies there is no reason to postpone a RSB in those infants. New methods, such as calretinin staining, must be considered to achieve better effectiveness of the RSB for diagnosing HD.

To present our experience of patients with Hirschsprung disease (HD) operated by transanal endorrectal descent (TED).A retrospective study performed of TEDs. We correlate fundamentally the aganglionic segment length with: Complications, need for colostomy and surgical approach.Between 2003 and 2012 we performed 73 TED (57 men), 78.6% diagnosed in the neonatal period. The aganglionic segment length evidenced in the enema was correlated with surgical findings in 68.9% of cases, being higher in the short forms than in the long segments (80.9 vs. 44%, P.001). Four patients required preoperative colostomy. The mean age of surgery was 6.3 months (4.5 to 33.7). Short forms represented 64.4% of cases. The abdominal approach was necessary in 10 patients, 9 of these were long/total colonic aganglionic segment. Postoperative enterocolitis presented in 10,9% (9 patients), with no relation with the length of aganglionic or the existence of residual dysplasia. Obstructions occurred in 19.2% of the long form or pancolonic forms. Currently, of the evaluable patients, 5 present constipationand 12 present occasional leakage.TED is the surgery of choice for patients with HD. The majority can be handled by preoperative «nursing» without colostomy. The diagnostic tests of choice are manometry with suction biopsy. No significant correlation was found between enterocolitis and length of aganglionic segment, although we observed a drastic reduction of postoperative enterocolitis, since the introduction of technical changes, such as the use of postoperative rectal tubes and the posterior section of the cuff muscles.

BACKGROUND & AIMS: Hirschsprung's disease (HD) is a rare birth defect of the distal colon. Analysis of rectal suction biopsy (RSB) is considered to be the most reliable method for its diagnosis in infants. However, the diagnostic accuracy of RSB analysis could be affected by the patient's age, possibly because of rapid development of the enteric nervous system in the first weeks after birth. Because there is a trend toward testing for HD at early ages, we aimed to determine whether the diagnostic accuracy of RSB analysis is associated with the patient's age.METHODS: We performed a retrospective analysis of all patients from whom 1 or more RSBs were analyzed from 1975 through 2011 (529 RSBs from 441 patients). Outcomes of RSB analyses were categorized as positive, inconclusive, or negative for HD. Primary diagnoses, based only on RSB, were compared with final diagnoses made after at least 1 year of clinical follow-up. Age at time of RSB analysis was corrected for the gestational age. By using these criteria, we determined the diagnostic accuracy of RSB analysis for different age groups.RESULTS: RSB analysis identified HD in patients with sensitivity values of 46% (patients -45 to 7 days old), 47% (8-22 days old), and 62% (23-39 days old) (corrected for gestational age). The average sensitivity with which RSB analysis identified HD in patients older than 39 days was 88%. RSB identified HD in patients younger than 39 days old with significantly lower sensitivity than in older patients (50% vs 88%, P CONCLUSIONS: RSB analysis identifies HD in patients younger than 39 days old with only 50% sensitivity. Moreover, RSBs obtained from younger patients often lead to inconclusive outcomes and require additional biopsies. We propose that for infants suspected of HD at these ages, a noninvasive technique, such as anorectal manometry, should be used for a primary diagnosis. RSB should thereafter be used to confirm the diagnosis when the infant is older than 39 days.

The objectives of this study were to recommend sample collection method(s) based on relative soiling in patient-used gastrointestinal (GI) endoscopes and determine whether the published benchmarks for protein, bioburden, and adenosine triphosphate (ATP) remain relevant for pump-assisted manual cleaning.Patient-used gastroscopes, duodenoscopes, and colonoscopes were sampled before and after manual cleaning and assessed for protein, bioburden, and ATP levels. The biopsy port (BP) to distal end (D) sample was collected using 20 mL of sterile reverse-osmosis water. After a 200-mL flush, the umbilical (UM) to BP portion was sampled by flushing 40 mL from the UM to the D.The BP to D portion of the suction biopsy channel contained 83% of ATP residuals. Despite cleaning with brushing and a flushing pump, 25% of gastroscopes exceeded the ATP benchmark of 200 relative light units (RLU), whereas all duodenoscopes and colonoscopes had200 RLU after cleaning. The protein and bioburden residuals after pump-assisted cleaning were consistently lower than existing benchmarks.Sampling the suction biopsy channel from BP to D detected the most residuals from patient-used GI endoscopes. The protein and bioburden benchmarks for pump-assisted cleaning can be lowered, but 200 RLU is still adequate for ATP.

Introduction This study investigates the use of rectal suction biopsy (RSB) with calretinin immunohistochemical staining (CIS) in patients suspected of having abnormally innervated bowel after pull through operation for Hirschsprung disease (HD). Method This study was conducted in Children's Hospital 2, Ho Chi Minh City from January 2015 through June 2016. Patients suspected with abnormally innervated bowel after pull through operation for HD were submitted for a RSB with CIS. Following histological results, the patients underwent an appropriate treatment (redo pull through operation or non-operative medical management) and followed up at least 6 months to evaluate their outcomes. Results Ten patients were enrolled in our study. The median age was 5.6 (range 1.4–20) years. The diagnosis of normally innervated bowel was made in five patients by showing positive reactivity of CIS on RSB, whereas five others were diagnosed with abnormally innervated bowel. Final diagnosis of the five latter patients was confirmed by analyses of the resected bowel after a redo pull through operation (including 4 cases with residual aganglionosis and one case with transition zone bowel). Conclusions RSB with CIS is a reliable and simple method for diagnosis of abnormally innervated bowel after pull through operation for HD. Level of evidence III Type of study Study of diagnostic test (evaluate the effectiveness of a diagnostic test or outcome assessment).

Objectives The aim of the study was to determine rates of histologically positive, negative, and inconclusive rectal suction biopsies in post-pull-through patients with Hirschsprung disease evaluated for potential residual aganglionosis at our institution and to determine how patients were managed after a post-pull-through rectal suction biopsy. Methods Thirty-nine post-pull-through suction biopsies from our institution were reviewed. Samples, stained with H&E and often acetylcholinesterase and/or calretinin, were categorized as "histologically" positive, negative, or inconclusive for aganglionosis. Subsequent clinical action was categorized as bowel resection, no further procedure, or rebiopsy. Agreement between histologic diagnosis and clinical action was assessed. Results Histologically, all biopsies were inconclusive (46%) or negative (54%) for residual aganglionosis. Postbiopsy clinical action included redo pull-through (5%), no further procedure (59%), or rebiopsy (36%). Rebiopsy was sought in 2 of 21 histologically negative patients and in only 12 of 18 histologically indeterminate patients. Eventual redo pull-through procedures in 6 of 39 patients showed 4 with residual aganglionosis and 2 with abnormalities suggesting residual "transition zone." Conclusions Our findings show that suction biopsy after pull-through was frequently histologically indeterminate and never definitively positive for residual aganglionosis. When biopsy was histologically indeterminate, rebiopsy was pursued less commonly than may be expected. Our findings emphasize that suction biopsy examination is not a "criterion standard" for residual aganglionosis, but instead a component of a diagnosis that ultimately combines clinicopathologic factors, the constellation of which can sometimes spare patients from a more invasive full-thickness biopsy.

Variability in cholinergic innervation may contribute to false-negative and false-positive evaluations for Hirschsprung disease (HD). We compared intraspecimen variability of histochemical acetylcholinesterase (ACE) activity in 62 distal rectal mucosal biopsy specimens from 33 patients with short-segment HD (SSHD), 14 patients with short-segment HD/Down syndrome (SSHD/DS), 10 patients with total colonic aganglionosis (HDTC), and 45 ganglionated control specimens obtained because of clinical suspicion for HD. Specimens were evaluated in 1-mm linear segments for abnormal distribution and abnormal intensity of staining reaction in the lamina propria (LP), muscularis mucosae (MM), numerical excess of small submucosal nerves (SSN), and presence or absence of large submucosal nerves (LSN) defined as >35 microns in diameter. Patients with HD and controls were predominantly infant males. Aggregate length of specimens was 186 mm in HD and 136 mm in controls. We defined multiple patterns and relative frequencies of normal and abnormal ACE reactivity in the muscularis mucosae, submucosal nerves, and innervation in the lamina propria. We verified a hyperinnervation pattern more common in neonates within each subset of HD. Large submucosal nerves >35 microns in diameter are relatively less common in SSHD/DS and HDTC. Eleven of 57 patients with HD had at least 1 mm of normal muscularis mucosae accounting for 19/186 mm examined. Ten percent of control mm had at least 1 submucosal nerve >35 microns in diameter. Intraspecimen variability in ACE patterns, when extreme, can usually be resolved by findings elsewhere in an adequate specimen, minimizing the need for repeat procedures.

Conventional acetylcholinesterase (AChE) histochemistry is both time consuming and complicated and requires the mixing of reagents that are toxic to the human body. We developed a rapid technique for performing AChE histochemistry, which has already been published, and now present a kit for performing AChE histochemistry that is a further improvement. Rectal suction biopsy specimens taken from 20 constipated patients and three full thickness biopsy specimens taken from 4 Hirschsprung's disease (HD) patients during pull-through surgery from aganglionic, transitional, and ganglionic bowel segments were tested using our rapid technique and the new kit. Each specimen was incubated for only 6 min. All ganglion cells stained clearly for AchE in just 6 min using both techniques. However, the kit was able to stain AchE positive nerve fibers more clearly and did not detect endogenous peroxidase-containing histiocytes, as did the earlier rapid technique. The kit could also detect AchE positive nerve fibers in the circular and longitudinal muscle layers, unlike the earlier rapid technique. The kit allows AChE histochemistry to be performed rapidly with complete accuracy, without any risk for toxicity. Moreover, the kit provides more focused information on AchE distribution in the bowel itself without any extraneous staining and can be used for diagnosing HD and allied disorders as well as establishing the exact level of innervation for pull-through resection.

Coeliac disease (CD) is a chronic enteropathy caused by intolerance to gluten in genetically susceptible people. The first description of the coeliac lesion was provided in 1954 by Paulley et al, who examined full-thickness biopsy specimens taken at laparotomy from a patient with CD. They referred to broad flat villi and a dense chronic inflammatory cell infiltrate in the small intestinal mucosa. Following this, the use of unguided suction biopsy devices, such as the Crosby capsule, allowed the study of patients with malabsorption. The advent of fibreoptic endoscopy as a diagnostic tool has led to extensive study of the duodenal mucosa in less florid forms of CD.

Summary Hirschsprung's disease (HSCR) is a polygenic disease for which the most important genetic loci are now known. It affects about 1/5000 live births with a potentially lethal neonatal bowel obstruction. It may present later as intractable constipation, but this is rare. Treatment relies on timely diagnosis, which, in a minority will be facilitated by recognition of associated syndromes. The reference standard of diagnosis is the rectal suction biopsy, although ano-rectal manometry has a place, and the clinician should be able to recognise the appearance of HSCR on contrast enema. Treatment is surgical, by resection of the aganglionic segment. This can be done as a neonatal one-stage operation in most cases. Despite the success of surgery in saving life, continence and bowel habit are frequently disturbed, at least up until puberty.

Introduction Since Noblett ( J Pediatr Surg 1969;4:406-409) described her innovative tool, rectal suction biopsy (RSB) has become the gold standard in the diagnosis of Hirschsprung's disease and other intestinal dysganglionoses. Many different instruments have been developed during the last 30 years, but none of them proved to be free of disadvantages. In 2000, at Gaslini Research Institute, we developed an improved tool to perform RSBs called Solo-RBT (SAMO Biomedica, Bologna, Italy), which has some advantages: (1) the procedure is easily performed by one operator alone; (2) the instrument can be adjusted for each patient according to age and weight; and (3) the instrument can be completely disassembled for decontamination and heat sterilization. This study describes our experience with Solo-RBT in the diagnosis of intestinal dysganglionoses. Materials and Methods Between February 2000 and January 2005, we performed RSBs on 389 patients. Detailed information regarding patients, technique, histochemical staining, diagnostic criteria, complications, and diagnoses are provided. Moreover, patients were divided in 3 age-related groups to compare results. Results One thousand twelve biopsies were performed on 389 patients. Age range at biopsy was 4 days to 66 years. Median age was 2.4 years. Each patient underwent a mean of 2.6 biopsies. Fifty-nine patients experienced complications, including 2 persistent rectal bleedings (0.5%) in patients younger than 1 year and 57 inadequate biopsies (14.5%). Neither perforation nor pelvic sepsis occurred. Sixty-five cases of Hirschsprung's disease and 58 of intestinal neuronal dysplasia have been diagnosed with Solo-RBT. Conclusions The very low incidence of major complications proved that Solo-RBT is safe and effective. The wide age range at biopsy confirms the great versatility of this tool. Our study demonstrated that age does not represent a risk factor for inadequacy of the specimen; however, it showed that patients younger than 1 year have a higher risk of major complications. Therefore, although Solo-RBT increases safety and reliability of RSBs, great attention should be paid when this procedure is performed in newborns and infants.

rectal suction biopsy is a safe and painless procedure commonly performed in pediatric surgical practice for the diagnosis of intestinal dysganglionosis.we report a 3.5-year-old boy who experienced massive delayed bleeding after a rectal suction biopsy. Detailed information regarding clinical features, onset, management, and outcome are provided.acute onset of massive bleeding occurred 4 days after a rectal suction biopsy was performed to rule out possible intestinal dysganglionosis. The complication was managed conservatively, but blood transfusion and hospitalization were required. No predisposing abnormalities were detected.massive bleeding after rectal suction biopsy is a well-known life-threatening complication. Nonetheless, such a delayed bleeding (up to 4 days after a rectal suction biopsy) has never been reported before. Parents should be made aware of this possibility and surgeons should be aware of this complication which can be scarcely predicted based on patient's and familial history.

Background: The diagnosis of Hirschsprung's disease (HD) is dependent on the histological study of rectal ganglion cells, and an open rectal biopsy was the mainstay that required general anaesthesia (GA) and carried risk of postoperative rectal bleeding. Suction rectal biopsy later gained wide acceptance and became the choice as there is no requirement of GA and virtual absence of any complications. Materials and Methods : A retrospective review of the histological findings of 216 rectal suction biopsies studied from 2005 to 2009. Results : There were 143 male and 73 female children. 196 (90.7%) children were within 1 year of age. Among 216 rectal suction biopsies 181 (83.80%) were aganglionic, 27 (12.5%) were ganglionic and 8 (3.7%) were inadequate. Majority of patients were of less than 1 year of age (94.47%). Conclusions : The rectal suction biopsy is a bed side procedure, safe, cheap and time saving. There is high degree of accuracy, simplicity and absence of complications.

During a 3-year period, 258 infants and children underwent rectal biopsy to exclude Hirschsprung's disease (HD) and related disorders; 32 (12%) were found to have HD. Major morbidity occurred in 3 (2%) of 148 patients undergoing rectal suction biopsy (RSB) and 22 (13%) of 168 suction biopsies were inadequate for diagnosis. In 102 children over 6 months of age, Storz rectal cup biopsy forceps were used with no significant morbidity and adequate biopsies were obtained in 96% of cases. Open rectal biopsy was performed in 8 patients. The RSB tube is safe and reliable, but attention to technique is important. For children over 6 months of age undergoing rectal biopsy for HD, the Storz rectal cup biopsy forceps yields superior results.

The practice of pediatric gastrointestinal pathology provides specific challenges to the pathologist. Often the clinical information accompanying a biopsy specimen will read simply, "failure to thrive." Other situations, such as the evaluation of a neonate's rectal suction biopsy for Hirschsprung disease, are notorious for providing diagnostic challenges in high-pressure situations. In this review, we will discuss several commonly encountered situations in pediatric pathology: the evaluation of pediatric esophageal eosinophilia, a child who has swallowed a non food item, caustic substance, or hot liquid, the evaluation of a pediatric colorectal biopsy with focal active colitis, and the evaluation of rectal suction biopsies for Hirschsprung disease. With each topic, we will discuss a general approach to the case, diagnostic tips, and how to avoid commonly encountered pitfalls. Finally, we highlight key references pertinent to these issues that can he used to help convey pathologic findings to pediatric gastroenterologists.

Serial biopsies of the colon may be necessary in order to diagnose etiology of chronic constipation when rectal suction biopsy results are inconclusive. Laparoscopy provides an excellent minimal invasive option in obtaining multiple biopsies of the colon for histological evaluation. Laparoscopic extramucosal biopsies can be obtained using a simple 3 port technique and no prior bowel preparation is mandatory. When compared to full thickness biopsies, extramucosal colon biopsies offer the advantages of obtaining biopsy specimens without breaching the integrity of the colon mucosa. In case the mucosa is opened, simple intracorporeal suturing of the biopsy site can be performed laparoscopically. Laparoscopic extramucosal colon biopsies can be performed as a days care procedure and is associated with a low morbidity. The technique is well suited for the pediatric age group.

PURPOSE To determine the control and performance characteristics of eight different suction biopsy devices. MATERIALS AND METHODS Physician control of the syringe and needle was measured precisely with the validated linear displacement method during the aspiration phase and during five biopsy passes. The visual analog scale was used to measure operator difficulty in the following domains: (i) attachment to the needle, (ii) generation of vacuum, (iii) detection of loss of vacuum, (iv) release of the vacuum, and (v) clearing of the sample from the needle. RESULTS Performance in various phases of the biopsy procedure varied widely among the biopsy devices tested. Unintended forward penetration (ie, loss of control in the forward direction) was significant with the reverse aspiration syringe (31.5 ± 1.7 mm), three-ringed control syringe (25.4 ± 4.1 mm), BioSuc-C7 syringe (28.3 ± 1.9 mm), conventional syringe with a plunger lock (6.1 ± 1.5 mm), syringe pistol (9.2 ± 2.4 mm), and conventional syringe (3.8 ± 2.9 mm) but was significantly less for the reciprocating procedure device (RPD; 0.7 ± 0.7 mm; P ≤ .001) and RPD syringe holder (0.6 ± 0.6 mm; P ≤ .001). The mean performance rankings were the best for the RPD (3.42 ± 2.57) and RPD syringe holder (4.29 ± 2.50) and worst for the conventional syringe (6.14 ± 2.67; P ≤ .001) and conventional syringe with a plunger lock (6.86 ± 3.80; P ≤ .001). CONCLUSIONS Each of the suction biopsy devices has unique advantages and disadvantages. Suction biopsy devices with the least favorable overall performance were the conventional syringe and the conventional syringe with a plunger lock. The highest overall performance was seen with the RPD and RPD syringe holder.

Suction rectal biopsy with acetylcholinesterase (AChE) histochemistry has been recognized as a reliable method for the diagnosis of Hirschsprung’s disease (HD). This study compares the final pathologic diagnosis made on paraffin embedded material of 68 colectomy specimens with the histochemical AChE reaction from the same patients previously diagnosed as HD by rectal suction biopsy at the Hospital Infantil Pequeno Príncipe (Curitiba, Brazil) from 1988 to 1999. The group included 58 male and ten female patients with ages ranging from 7 days to 10 years. Thirty-six patients (52.94%) where under 1 year of age at time of surgery. Two of the 68 patients had previous normal histochemical reactions for AChE: one of them resulted a normal ganglionic segment of bowel and the other one was a 15-day-old boy with total colonic aganglionosis, the only false-negative result in this series. Two patients had inconclusive results and because untreatable clinical symptoms also received surgical treatment. One of them resulted a normal ganglionic bowel and the other one was diagnosed as HD. All surgical specimens from the other 64 patients resulted in various extents of aganglionosis presenting prominent nerve trunks in the submucosal and myenteric plexuses, confirming the previous AChE histochemical diagnosis. In three cases there was total colonic aganglionosis. In this study the rectal suction biopsy associated with the histochemical method of AChE, performed days, months or sometimes years before surgery, resulted in a diagnostic accuracy rate of 95.59%, a positive predictive value of 100% and there were no false-positive results. A biópsia de reto por sucção associada à histoquímica enzimática pela acetilcolinesterase (AChE) tem sido reconhecida como um método confiável para o diagnóstico da doença de Hirshsprung (HD). Este estudo compara o diagnóstico patológico final de 68 peças de colectomias incluídas em parafina com o diagnóstico prévio de HD através da reação histoquímica da AChE em biópsia por sucção retal dos mesmos pacientes, todos operados no Hospital Infantil Pequeno Príncipe, de Curitiba, entre 1988 e 1999. No grupo há 58 pacientes masculinos e dez femininos com idades variando entre 7 dias e 1 ano, sendo que 33 pacientes (52,94%) tinham menos de 1 ano de idade no momento da cirurgia. Dos 68 pacientes, dois tiveram reação prévia normal pela AChE, porém, como persistiam com quadro de suboclusão intestinal, foram levados à cirurgia; um deles resultou HD, padrão aganglionose total do cólon, o único caso falso-negativo deste estudo. Outros dois pacientes tiveram resultado inconclusivo pela AChE, e um deles resultou HD no exame da colectomia. Todas as colectomias dos demais 64 pacientes resultaram agangliônicas (HD), apresentando proeminência de troncos nervosos nos plexos submucoso e mioentérico, confirmando o diagnóstico histoquímico prévio pela AChE. Em três casos havia aganglionose colônica total. Neste estudo a biópsia retal por sucção associada ao método histoquímico da AChE, realizado dias, meses ou anos antes da cirurgia, apresentou taxa de acurácia diagnóstica de 95,59%, valor preditivo positivo de 100% e nenhum resultado falso-positivo.

The authors present a neonatal case of allergic colitis, which manifested the difficulty of spontaneous defecation and irregular narrowing of distal rectum in contrast enema. Rectal suction biopsy showed positive acetylcholinesterase activity. These clinical, radiological and histological findings were indistinguishable from Hirschsprung’s disease. Gastrointestinal symptoms were improved by the cessation of cow’s milk formula. The present findings may impact on the less recognizable gastrointestinal manifestation of allergic colitis.