Qual é a melhor técnica de biópsia retal para o diagnóstico de disganglionoses intestinais em crianças? Uma revisão complementar através da análise de proporções de séries de casos.
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2019-02-28
Autores
Comes, Giovana Tuccille
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Universidade Estadual Paulista (Unesp)
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Introdução: A constipação intestinal é uma condição debilitante que afeta mais de 27% da população, representando um problema de saúde pública, além de corresponder a 3% de todas as consultas pediátricas. Existem várias causas congênitas e adquiridas. A Doença de Hirschsprung (DH) é a principal causa congênita de constipação e envolve 90% dos casos congênitos. O diagnóstico de disganglionoses intestinais depende da análise histopatológica de biópsias retais. Nessa revisão sistemática, levantamos todas as series de casos disponíveis na literatura e desenvolvemos uma metanálise de proporções para definer a taxa de resultados conclusivos e as complicações relacionadas aos diferentes tipos de biópsia retal no diagnóstico de disganglionoses intestinais. Métodos: A partir de ampla busca na literatura em múltiplas bases de dados, foi realizada uma revisão sistemática e metanálise de proporção das séries de casos que envolviam biópsias retais em pesquisa de disganglionoses intestinais em crianças. Foram incluídas series de casos que envolvessem mais de 5 biópsias em pacientes menores de 18 anos de idade com suspeita de disganglionose intestinal, que descrevesse ao menos um tipo de biópsia retal. Os estudos deviam especificar a taxa de resultados conclusivos e a taxa de complicações das técnicas de biópsias. A análise de proporção de série de casos foi realizada e os resultados apresentados em gráficos do tipo forest plot. Resultados: Foram selecionados 151 estudos pelos critérios de elegibilidade e 63 foram submetidos a metanálise de proporções, totalizando 16,769 pacientes e 23,667 biópsias retais. A proporção da taxa de resultados conclusivos foi de 95% (95% CI, 0.87–0.99) em biópsias cirúrgicas; 95% (95% CI, 0.90–0.98) em punch e 88% (95% CI, 0.85–0.92) para sucção. Para a biópsia de sucção, em pacientes menores de 36 meses de idade, a taxa de resultados conclusivos foi de 84% (95% CI, 0.77–0.90) enquanto que em maiores de 36 meses foi de 78% (95% CI, 0.69–0.85). A proporção para resultados conclusivos de acordo com a análise histopatológica foi de 89% (95% CI, 0.83–0.93) para HE; 95% (95% CI, 0.90–0.99) para AChE; 89% (95% CI, 0.81–0.95) em HE + AChE e o grupo HE + calretinina com ou sem AChE apresentou 94% (95% CI, 0.89–0.98). A proporção de taxa de resultados conclusivos para pacientes submetidos a biópsia cirúrgica foi de 100% (95% CI, 0.98–1.00) no grupo para análise com AChE; 94% (95% CI, 0.88–0.98) na análise com HE e 97% (95% CI, 0.87–1.00) em HE + AChE. Nos pacientes submetidos a biópsia por sucção, a análise da proporção da taxa de resultados conclusivos foi de 91% (95% CI, 0.85–0.95) no grupo com análise por AChE; 85% (95% CI, 0.74–0.93) no grupo HE; 86% (95% CI, 0.77–0.94) no grupo HE + AChE analysis group; e 92% (95% CI, 0.87–0.96) em HE + calretinina com ou sem AChE. A proporção das taxas de complicações foi de 1% (95% CI, 0.00019–0.03) para biópsias cirúrgicas, 0.03% (95% CI, 0.00019–0.00051) para sucção e 2% (95% CI, 0.00075–0.04) em biópsias por punch. Conclusão: Essa é a primeira revisão sistemática com metanálise de proporção que compara a taxa de resultados conclusivos dos diferentes tipos de biópsias retais e que considera a taxa de complicações de cada uma. As taxas de resultados conclusivos não tiveram diferença estatisticamente significante entre as biópsias retais por punch, sucção e cirúrgicas. No entanto, as biópsias por punch apresentaram taxas superiores com significância estatísticas para complicações quando comparadas ao grupo submetido a biópsias por sucção. As biópsias por sucção apresentaram taxas de resultados conclusivos semelhantes entre os dois grupos estabelecidos por faixa etária, mantendo sua indicação mesmo para crianças maiores. Nossos resultados reforçam a importância da associação de diferentes métodos de análises histopatológicas, principalmente em biópsias por sucção. Palavras chaves: constipação, disganglionoses intestinais, Doença de Hirschsprung, biópsias retais.
Introduction: Intestinal constipation is a debilitating condition that affects up to 27% of the population, representing an important public health problem and corresponding to 3% of all pediatric consultations. There are many different congenital and acquired conditions, but Hirschsprung’s disease (HD) is the main representative entity of congenital disease and is involved in 90% of all cases. The diagnosis of intestinal dysganglionosis depends on the histopathological analysis of rectal biopsies. Here we conducted an updated systematic review of all case series studies available in the literature and performed a pooled analysis of proportions to assess the rate of conclusive results and possible complications of different rectal biopsy techniques in the diagnosis of intestinal dysganglionosis. Methods: A broad literature search using multiple online databases. A systematic literature review and proportional meta-analysis of the available case series studies of rectal biopsies in the diagnosis of intestinal dysganglionosis in children were performed. We included case series with more than 5 rectal biopsies in children under 18 years of age suspected of intestinal dysganglionosis, that described at least one type of rectal biopsy. The studies should have specified the rate of conclusive results and the rate of complications of the biopsy procedures. Proportional meta-analysis of case series studies was performed and forest plot charts were created to summarize the data. Results: There were 151 included studies according to eligibility criteria and 63 were included in proportional meta-analysis, ranging 16,769 patients and 23,667 rectal biopsies. The pooled proportion of conclusive results was 95% (95% CI, 0.87–0.99) in open biopsies; 95% (95% CI, 0.90–0.98) in punch and 88% (95% CI, 0.85–0.92) in suction. The pooled proportion of conclusive results in the group of patients undergoing suction biopsies was 84% (95% CI, 0.77–0.90) of patients younger than 36 months old and 78% (95% CI, 0.69–0.85) of patients older than 36 months old. The pooled proportion of conclusive results was 89% (95% CI, 0.83–0.93) in the HE analysis; 95% (95% CI, 0.90–0.99) in the AChE analysis; 89% (95% CI, 0.81–0.95) in HE with AChE analysis and in HE with calretinin with or without AChE group, there was 94% (95% CI, 0.89–0.98). The pooled proportion of conclusive effects in patients undergoing open biopsies regarding to the histopathological analysis was 100% (95% CI, 0.98–1.00) in the AChE analysis group; 94% (95% CI, 0.88–0.98) in the HE analysis group and 97% (95% CI, 0.87–1.00) in the HE + AChE analysis group. In the suction group, the pooled proportion of conclusive effects was 91% (95% CI, 0.85–0.95) in the AChE analysis group; 85% (95% CI, 0.74–0.93) in the HE analysis group; 86% (95% CI, 0.77–0.94) in the HE + AChE analysis group; and 92% (95% CI, 0.87–0.96) in the HE + calretinin with or without AChE analysis group. The pooled proportion of complication rates was 1% (95% CI, 0.00019–0.03) in open biopsies. There was a 0.03% rate (95% CI, 0.00019–0.00051) in suction biopsies, and the pooled complication rate was 2% (95% CI, 0.00075–0.04) in punch biopsies. Conclusion: This is the first systematic review and meta-analysis to compare the rate of conclusive results obtained by the different types of rectal biopsies techniques, also considering their rate of complications. The conclusive result rates of open, suction, and punch biopsies did not differ significantly. However, punch biopsies demonstrate significantly higher complication rates than suction biopsies. Suction rectal biopsies also demonstrated similar conclusive rates across different mean age groups, supporting their indication even for older children. Our results reinforce the value of the association between different adjuvant methods in the histopathological analysis, mainly in rectal suction biopsies. Key words: constipation, intestinal dysganglionosis, Hirschsprung Disease, rectal biopsies.
Introduction: Intestinal constipation is a debilitating condition that affects up to 27% of the population, representing an important public health problem and corresponding to 3% of all pediatric consultations. There are many different congenital and acquired conditions, but Hirschsprung’s disease (HD) is the main representative entity of congenital disease and is involved in 90% of all cases. The diagnosis of intestinal dysganglionosis depends on the histopathological analysis of rectal biopsies. Here we conducted an updated systematic review of all case series studies available in the literature and performed a pooled analysis of proportions to assess the rate of conclusive results and possible complications of different rectal biopsy techniques in the diagnosis of intestinal dysganglionosis. Methods: A broad literature search using multiple online databases. A systematic literature review and proportional meta-analysis of the available case series studies of rectal biopsies in the diagnosis of intestinal dysganglionosis in children were performed. We included case series with more than 5 rectal biopsies in children under 18 years of age suspected of intestinal dysganglionosis, that described at least one type of rectal biopsy. The studies should have specified the rate of conclusive results and the rate of complications of the biopsy procedures. Proportional meta-analysis of case series studies was performed and forest plot charts were created to summarize the data. Results: There were 151 included studies according to eligibility criteria and 63 were included in proportional meta-analysis, ranging 16,769 patients and 23,667 rectal biopsies. The pooled proportion of conclusive results was 95% (95% CI, 0.87–0.99) in open biopsies; 95% (95% CI, 0.90–0.98) in punch and 88% (95% CI, 0.85–0.92) in suction. The pooled proportion of conclusive results in the group of patients undergoing suction biopsies was 84% (95% CI, 0.77–0.90) of patients younger than 36 months old and 78% (95% CI, 0.69–0.85) of patients older than 36 months old. The pooled proportion of conclusive results was 89% (95% CI, 0.83–0.93) in the HE analysis; 95% (95% CI, 0.90–0.99) in the AChE analysis; 89% (95% CI, 0.81–0.95) in HE with AChE analysis and in HE with calretinin with or without AChE group, there was 94% (95% CI, 0.89–0.98). The pooled proportion of conclusive effects in patients undergoing open biopsies regarding to the histopathological analysis was 100% (95% CI, 0.98–1.00) in the AChE analysis group; 94% (95% CI, 0.88–0.98) in the HE analysis group and 97% (95% CI, 0.87–1.00) in the HE + AChE analysis group. In the suction group, the pooled proportion of conclusive effects was 91% (95% CI, 0.85–0.95) in the AChE analysis group; 85% (95% CI, 0.74–0.93) in the HE analysis group; 86% (95% CI, 0.77–0.94) in the HE + AChE analysis group; and 92% (95% CI, 0.87–0.96) in the HE + calretinin with or without AChE analysis group. The pooled proportion of complication rates was 1% (95% CI, 0.00019–0.03) in open biopsies. There was a 0.03% rate (95% CI, 0.00019–0.00051) in suction biopsies, and the pooled complication rate was 2% (95% CI, 0.00075–0.04) in punch biopsies. Conclusion: This is the first systematic review and meta-analysis to compare the rate of conclusive results obtained by the different types of rectal biopsies techniques, also considering their rate of complications. The conclusive result rates of open, suction, and punch biopsies did not differ significantly. However, punch biopsies demonstrate significantly higher complication rates than suction biopsies. Suction rectal biopsies also demonstrated similar conclusive rates across different mean age groups, supporting their indication even for older children. Our results reinforce the value of the association between different adjuvant methods in the histopathological analysis, mainly in rectal suction biopsies. Key words: constipation, intestinal dysganglionosis, Hirschsprung Disease, rectal biopsies.
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Palavras-chave
constipação, disganglionoses intestinais, Doença de Hirschsprung, biópsias retais, constipation, intestinal dysganglionosis, Hirschsprung Disease, rectal biopsies