Role of rectal biopsy in predicting response to intrasphincteric botulinum toxin injection for obstructive symptoms after a pullthrough operation.
OBJECTIVE
Our aim was to correlate the pathological results and clinical response in patients who underwent botulinum toxin (BT) injection for obstructive symptoms (OS) after a pullthrough operation for Hirschsprung's disease (HD).


METHODS
Between August 2002 and February 2006, 16 of 107 HD patients (15%) were referred with persistent OS after pull-through (PT) operation in this center. They underwent rectal biopsy and BT injection in the internal sphincter. Their responses to BT injection were evaluated by the constipation score before, and at 1, 3 and 8 months after the injection, and anorectal manometry (ARM) before and at 2 weeks, and 1 and 8 months after the injection. The association between response to BT and acetylcholinesterase (AChE) staining of rectal biopsy was also assessed.


RESULTS
Fourteen of 16 patients (87%) had improvement in bowel function after 2 weeks, and two patients did not respond at all. Six of the 14 patients with early response had recurrence of symptoms after 2-3 months. Eight patients with normal ganglia and negative AChE had good response with no recurrence on follow-up. However, 4 of 6 recurrences were neurogenic dysfunctions and 2 were intestinal neuronal dysplasia (2-4+AChE). Two patients with no response had an aganglionic segment (4+AChE). Four of 6 patients with recurrence showed improvement with BT re-injection and only 2 did not improve.


CONCLUSIONS
A higher degree of AChE staining is associated with lack of response to BT injection. This is also a test for predicting the severity of neurogenic dysfunction in the intestinal wall.
Hosseini
Seyed Mohammad Vahid
SM
Department of Pediatric Surgery, Shiraz University of Medical Sciences, Shiraz, Iran. psrg.sums@yahoo.com
Foroutan
Hamid Reza
HR
Bahador
Ali
A
Khosravi
Mohammad Bagher
MB
Geramizadeh
Bita
B
Sabet
Babak
B
Zeraatian
Sam
S
Razmi
Tannaz
T
Banani
Seyed Javad
SJ
D000110:Acetylcholinesterase / Q000378:metabolism; D001003:Anal Canal; D001706:Biopsy; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003248:Constipation / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006627:Hirschsprung Disease / Q000201:enzymology / Q000473:pathology* / Q000601:surgery; D006801:Humans; D007273:Injections, Intramuscular; D007415:Intestinal Obstruction / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*; D008297:Male; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D011183:Postoperative Complications; D011237:Predictive Value of Tests; D012007:Rectum / Q000473:pathology*; D016896:Treatment Outcome
D009465:Neuromuscular Agents; D000110:Acetylcholinesterase; D019274:Botulinum Toxins, Type A