Endoscopy 2018; 50(10): E281-E283
DOI: 10.1055/a-0642-9017
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic full-thickness resection for diagnosis of Hirschsprung’s disease

Alvaro Martínez-Alcalá
1  Centro de Innovaciones Digestivas Martínez-Alcalá (CIDMA), Seville, Spain
,
Felipe Martínez-Alcalá García
1  Centro de Innovaciones Digestivas Martínez-Alcalá (CIDMA), Seville, Spain
,
Klaus Mönkemüller
2  Frankenwald Klinik, Kronach, Germany
,
Helmut Neumann
3  University Medical Center Mainz, Mainz, Germany
,
Felipe Martínez-Alcalá
1  Centro de Innovaciones Digestivas Martínez-Alcalá (CIDMA), Seville, Spain
› Author Affiliations
Further Information

Publication History

Publication Date:
03 July 2018 (eFirst)

Endoscopic full-thickness resection (EFTR) is beneficial for treating a variety of conditions of the lower gastrointestinal tract such as early cancers, polyps, and fistulas [1] [2]. Whereas the role of EFTR in the therapy for these conditions has been proven to be effective and safe, there is a paucity of data about its potential utility as a diagnostic intervention in patients with gastrointestinal tract dysmotility disorders [3]

In this report, we present a 19-year-old woman with chronic constipation since childhood, which remained severe, despite the use of multiples laxatives, along with dietary and lifestyle changes. Apart from the severe, recalcitrant constipation, the patient had no significant past medical history. The family history, however, was positive for achalasia in her mother.

The patient underwent several diagnostic interventions. A colonoscopy was unrevealing, except for massive dilatation of the sigmoid and descending colon and stool retention despite aggressive bowel prep and intraprocedural bowel cleansing. Histology obtained using the biopsy-on-biopsy technique was unrevealing. Both anorectal manometry and barium enema were suggestive of Hirschsprung’s disease. To obtain a definitive diagnosis, a full-thickness tissue sample was required. Traditionally, surgery is mandatory to obtain such tissue. However, the advent of the EFTR device (Ovesco, Tübingen, Germany) allows for the retrieval of the entire wall of the gastrointestinal tract. The patient decided to accept the use of this method and consented to undergo FTR using endoscopic means ([Fig. 1]; [Video 1]). The sample obtained was 15-mm wide and included down to the deep submucosal and muscular layers. After performing special immunohistochemical stains (S-100, synaptophysin, calretinin, and neurofilament specific), a diagnosis of hypoganglional disease was reached ([Fig. 2])

Zoom Image
Fig. 1 Endoscopic images showing: a the lesion being marked; b the tissue being pulled inside the transparent distal cap; c the pulled-in tissue being snared; d the resection site with over-the-scope clip (OTSC) in situ.

Video 1 Endoscopic full-thickness resection using the Ovesco device including a step-by-step description of the technique, which involves marking of the lesion, grasping and retrieval of the target tissue within the cap then fixation, release of the over-the-scope clip (OTSC) with a hand-wheel, closure of the snare and electrical cutting of the target tissue, and finally inspection of the resection site.

Georg Thieme Verlag. Please enable Java Script to watch the video.
Zoom Image
Fig. 2 Histological appearances of the resected specimen stained with hematoxylin and eosin (H&E) and immunostained with calretinin and S100.

As we can see in this case, diagnosis by EFTR appears to be a safe, fast, and feasible option to obtain enough tissue from the deeper layers of the rectum to diagnose Hirschsprung’s disease and other deep-seated disease processes, instead of the typical invasive surgical procedures. Therefore, the advent of the EFTR device has increased our ability to help patients obtain an earlier diagnosis of their chronic, underlying illness. This case adds to the literature on the diagnostic utility of EFTR.

Endoscopy_UCTN_Code_CCL_1AD_2AJ

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos