How can we proceed intra-operative decision for resecting the a ganglionic segment without the help of a Frozen section?
Can we base on the contrast enema?In country we lack of expert in Histopathology in HD?
Pre operatively , the surgeon should have an idea about the length of the aganglionic segment, the site of the transition zone. and accordingly he should plan the surgery. per operative the surgeon should decide according to the result of frozen section biopsy.
Dear colleague, it is practically impossible to decide the resection line in HD patients intraoperatively without histology. The only way could be to do first a laparoscopy or limited laparotomy and do serial biopsies, which must be evaluated by histochemistry. This will enable you to know the exact anatomy, i.e. aganglionic zone, transitional zone and normal ganglionic zone.
If you have problems with experts on pathohistology in HD, you might consider taking the biopsies and sending them to an expert lab.
Regards
Udo
I agree with most of what the other respondents have said. Cannot be safely done without frozen section guidance. H&E is fine. For maximum security we recommend a small full thickness intraoperative biopsy to determine the safely ganglionated zone because seromuscular bx may be misleading in transition zone. The surgeon should take a few extra cm for best result or check proximal margin before closing.
farid if you have not a pathology you have to decide only viewing the bowel. Remain 2-3-4 -5 cm up in the dilated bowel . good job!! Piergiorgio
Well, it is not an easy job but as the respected colleagues did mention that the best will be the use of a frozen section if we are intended to do it via an abdominal approach whether laparoscopically or through laparotomy.
In case of intending to use the TREPT Soav's technique, it will be better to have a serial contrast studies x-ray series in the lateral view performed by an expert paediatric radiologist for a proper localization of the sites. Yet, the best will be to have a laparoscopic frozen section biopsy by applying the laparoscopically assisted TREPT.
Hi Farid, you can have a good aid in a good enema that depict the transitional zone, the smaller the baby the more difficult to identify this change. Definitely, imo, if you don't have an experienced pathologist in this matter you have to cut by viewing the bowel and deciding which diameter of the colon is the best for the anal anastomosis.
All the best!
Maurizio
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