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. 2021 Mar-Apr;26(2):111-116.
doi: 10.4103/jiaps.JIAPS_43_20. Epub 2021 Mar 4.

Routine use of Circumferential 'Doughnut' Biopsy in Pull through Surgery for Hirschsprung's Disease: Advantages and Limitations

Govind V S Murthi  1 , Oliver G Townley  1   2 , Richard M Lindley  1 , Marta C Cohen  3
Affiliations

Routine use of Circumferential 'Doughnut' Biopsy in Pull through Surgery for Hirschsprung's Disease: Advantages and Limitations

Govind V S Murthi et al. J Indian Assoc Pediatr Surg. 2021 Mar-Apr.

Abstract

Aims: The aim of this study was to review the use of the on-table "doughnut" biopsy for frozen section assessment of bowel in the operative management of Hirschsprung's disease (HD).

Methods: This was a single-center retrospective review of doughnut histopathology reports, operation notes, and slides from 2010 to 2017. Data were assessed for the presence of transition zone (TZ) features and the subsequent decision as to the level of pull-through.

Results: Fifty-five patients had a doughnut biopsy taken as part of their intraoperative frozen section histopathology for pull-through for HD during the study period. Forty-eight required a single doughnut, six required a second more proximal doughnut, and one required a third doughnut. Of the 55 first doughnuts, 37 were identified as normal bowel, 17 were TZ, and not defined in the report in one case. Of the 17 TZ doughnuts, 8 were accepted for pull-through and 7 underwent second doughnuts (normal = 4 and TZ = 3). The third doughnut (one case) was normal. TZ was accepted for pull-through in 10/54 (18.5%) patients despite the use of a doughnut. However, TZ was avoided in six (11.1%), where the single-point biopsy was "normal."

Conclusions: The doughnut allows the entire circumference of pull-through level to be assessed, enabling TZ identification that can be missed by single seromuscular biopsies. This allows identification and avoidance of TZ pull-through, although sometimes, it is accepted for other reasons.

Keywords: Doughnut; Hirschsprung's disease; frozen section; transition zone.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Doughnut biopsy showing thick nerves in the submucosa (arrow) (H and E, ×10). Inset: higher magnification of the thick nerve trunk (H and E, ×20)
Figure 2
Figure 2
Thick nerve trunks in the myenteric plexus (arrows). A ganglion cell is also present next to one of the thick nerve trunks (star) (H and E, ×20)
Figure 3
Figure 3
Flowchart showing the process followed in all 55 patients after initial doughnut biopsy at level of ‘normal’ bowel as identified by “single-point” biopsy
Figure 4
Figure 4
Photo of specimen of doughnut of colon taken for intraoperative frozen section assessment. The proximal margin is marked at the antimesenteric point with a suture for orientation
See this image and copyright information in PMC

References

    1. White FV, Langer JC. Circumferential distribution of ganglion cells in the transition zone of children with Hirschsprung disease. Pediatr Dev Pathol. 2000;3:216–22. - PubMed
    1. Gherardi GJ. Pathology of the ganglionic-aganglionic junction in congenital megacolon. Arch Pathol. 1960;69:520–3. - PubMed
    1. Kapur RP, Kennedy AJ. Transitional zone pull-through: Surgical pathology considerations. Semin Pediatr Surg. 2012;21:291–301. - PubMed
    1. Coyle D, O'Donnell AM, Tomuschat C, Gillick J, Puri P. The extent of the transition zone in Hirschsprung disease. J Pediatr Surg. 2019;54:2318–24. - PubMed
    1. Ghose SI, Squire BR, Stringer MD, Batcup G, Crabbe DC. Hirschsprung's disease: Problems with transition-zone pull-through. J Pediatr Surg. 2000;35:1805–9. - PubMed