Adult Hirschsprung's disease. Results of the Duhamel's procedure

Simultaneous degeneration of myenteric plexuses and pelvic parasympathetic colonic nerve in slow transit constipation: A case report

RATIONALE

Slow transit constipation (STC) is a common disease of which the etiology is still not clear. Multiple hypotheses have been proposed to explain STC, including autonomic neuropathy, disorders of the enteric nervous system and so forth. Morphological abnormalities of the enteric nerves of the colon in patients with STC have been extensively reported, while there have been no morphological reports focusing on extrinsic extramural fibers from the pelvic plexus to the distal colon (i.e., pelvic parasympathetic colonic nerve) in patients with STC.

PATIENT CONCERNS

Whether morphological changes of pelvic parasympathetic colonic nerve coexist with abnormalities of the enteric nerves of the colon in the patient with STC.

DIAGNOSIS

Slow transit constipation (STC).

INTERVENTIONS

The patient with STC underwent a partial colectomy (sigmoid colon and partial descending colon). The fibers of the myenteric plexuses within the removed colon and the myelinated fibers of the pelvic parasympathetic colonic nerve were observed under optical and electron-microscope.

OUTCOMES

The fibers of the myenteric plexuses showed vacuolated degeneration between the muscularis propria layer under optical microscope. Myelinated fibers of the pelvic parasympathetic colonic nerve showed obvious vacuolated degeneration under electron-microscopic examination.

LESSONS

Such a simultaneous neuropathy in both myenteric plexuses and extrinsic extramural nerves has not been documented previously. Our finding supports the notion that neuropathy remains the most plausible explanation for STC, in which nerve dysfunction might occur by way of a degenerative process.

Long-term outcomes and quality of life after subtotal colectomy combined with modified Duhamel procedure for adult Hirschsprung's disease

BACKGROUND

Subtotal colectomy combined with modified Duhamel procedure (Jinling procedure) was used in patients with adult Hirschsprung's disease (AHD) at Jinling Hospital in the last decade. The aim of this study is to evaluate the safety, effectiveness and quality of life of Jinling procedure for AHD.

MATERIALS AND METHODS

All the data are from the database of the Jinling Hospital Constipation Registry System. Primary outcomes, including safety (morbidity and adverse events), effectiveness (satisfaction rate, Wexner constipation scale (WCS) and bowel function score (BFS)) and gastrointestinal quality of life index (GIQLI), were all evaluated.

RESULTS

Fifty-nine patients were available for this study and the mean postoperative period was 44 months. Seventeen major complications were found in 11 patients and most of the complications could be managed conservatively. A significant improvement in WCS, BFS and GIQLI at 6 months postoperatively was obtained.

CONCLUSION

Jinling procedure is safe and effective for AHD.

Late diagnosis of Hirschsprung disease--patient characteristics and results

PURPOSE

The aim of the present study was to describe the characteristics and the postoperative results of children diagnosed as having Hirschsprung disease (HD) after the age of 3 years.

METHODS

All patients with HD diagnosed after the age of 3 years in our hospital from 1998 to 2011 were included. Patient characteristics and postoperative results were prospectively registered.

RESULTS

Eleven children were included. Age at diagnosis was 3.0 to 9.6 years. Ten patients had rectosigmoid disease, whereas 1 had total colonic aganglionosis. Three children were given a diverting ileostomy before the pull-through procedure, and all 3 had ileostomy-related complications. Early postoperative complications were seen in 5 children, of whom 2 had anastomotic leakage. At final follow-up, with a median of 3 years postoperatively, 7 had normal bowel function, 1 had frequent loose stools, and 3 were soiling.

CONCLUSIONS

Early postoperative complications, especially anastomotic leakage, occurred frequently in children with late-diagnosed HD. Therefore, a diverting stoma should be considered in these patients. The long-term functional results were comparable with those seen in children operated on as neonates.

One-stage transanal endorectal pull-through for treatment of hirschsprung's disease in adolescents and adults

BACKGROUND

One-stage pull-through operation has become increasingly popular for treatment of Hirschsprung's disease. The one-stage transanal pull-through was introduced in the late 1990s and has rapidly replaced traditional procedures in infants and young children in many surgical centers.

OBJECTIVE

The aim of this study is to determine feasibility and safety of transanal primary repair in adolescent and adults.

METHODS

Fifteen patients who underwent transanal endorectal pull-through were prospectively studied. All patients presented by chronic refractory constipation with the age ranged from 11 to 22 years. The patients were followed up for a mean of 18 months. Anal continence and postoperative complication were evaluated.

RESULTS

Incomplete continence in the form of soiling occurred in four patients (26.6%) and improved gradually with conservative management. No patients suffered from complete incontinence. Anastomotic strictures occurred in two patients and were successfully treated with regular dilatations. One patient had continued outlet obstruction and revision was considered for him. One patient complicated with low perianal fistula which needed fistulectomy. There was no impotence in adults.

CONCLUSION

These findings indicate that one-stage transanal endorectal pull-through operation in adolescent and adults is feasible and safe.

Laparoscopic rectosigmoid resection with transanal colonic pull-through and delayed coloanal anastomosis: a new approach to adult Hirschsprung disease

BACKGROUND

Hirschsprung disease in adults is a rare and frequently misdiagnosed cause of long-standing, refractory constipation. Surgical procedures initially developed for pediatric patients have been applied to adults with varying degrees of success.

OBJECTIVE

Our aim was to describe a new surgical procedure consisting of laparoscopic rectosigmoid resection with a transanal colonic pull-through followed by a delayed coloanal anastomosis for the treatment of Hirschsprung disease in adults and to present our preliminary results with this technique.

DESIGN AND SETTING

This was a descriptive observational study of treatment outcome conducted at the colorectal surgical unit of a university teaching hospital in France.

PATIENTS

Patients were adults with confirmed Hirschsprung disease treated from October 2006 through February 2009.

INTERVENTION

Laparoscopic rectosigmoid resection was performed with a transanal colonic pull-through followed by a delayed coloanal anastomosis.

MAIN OUTCOME MEASURES

Clinical and functional data (Cleveland Clinic Florida incontinence scale and Fecal Incontinence Quality of Life scale) were obtained at postoperative visits.

RESULTS

Five patients underwent the procedure. One patient died of postoperative cardiovascular complications. No patient had to be reoperated. No anastomotic leakage occurred. One patient developed anastomotic stricture requiring dilatation. No sexual or urinary dysfunction was reported. Postoperative analysis (mean follow-up 16 months) showed good functional outcomes in 3 (75%) of the 4 evaluable patients.

LIMITATIONS

This study had only a small number of patients and no controls other comparison with cases reported in the literature.

CONCLUSION

Laparoscopic rectosigmoid resection with a transanal colonic pull-through followed by delayed coloanal anastomosis represents a valid alternative in the treatment of Hirschsprung disease in adult patients, because it involves minimally invasive surgery, does not require a preventive diverting stoma, and shows anastomotic security.

Clinical features' diagnostics and treatment of Hirschsprung's disease in adults

AIM

Hirschsprung's disease first diagnosed in adulthood is symptomatic from early childhood in most cases. However, the condition is frequently masked when constipation is managed effectively by enemas and aperients. One third of the patients will experience progressive symptoms or complications, requiring urgent surgical intervention.

METHOD

Ninety patients with adult Hirschsprung's disease were observed by a combination of investigations: barium enema, anorectal physiology, estimation of acetylcholinesterase activity and a 60mm full-thickness strip biopsy. The latter two modalities were performed in selected patients where there was diagnostic uncertainty. Single-staged resections, mostly modified Duhamel procedures, were performed in patients who were stable and fit, and with only a limited degree of megacolon present, and no other complications. Otherwise patients were temporarily defunctioned prior to staged resection. All patients underwent surgical treatment. Long-term functional outcomes were expressed as good, satisfactory or poor.

RESULTS

Median age was 24.5 years, range 14-47 years, and 72.2% were men. Almost three quarters (73.3%) of the patients had symptoms dating from early childhood. Barium enema was diagnostic in 84.3%, and 36.2% had a positive, but weak rectoanal inhibitory reflex. Acetylcholinesterase staining was positive in 85.7%, but full-thickness strip biopsy was positive in 100% of equivocal cases. A separate cadaveric study of unaffected individuals determined the true length of the normal physiological hypoganglionic zone, mean 24.4 mm and range 7.5-50 mm. Supra-anal short segment Hirschprung's disease was found in 5.6% patients, rectal involvement in 54.4%, rectosigmoid in 38.9% and total aganglionosis of the colon in 1.1%. Resection of the aganglionic zone and proximally dilated colon was performed as a single-staged procedure in 67.8%. Staged surgery was carried out in 32.2%. A modified Duhamel procedure was performed in 91.2% of cases. A good or satisfactory functional outcome was achieved in 96.7%. Long-term functional outcome after resection depends on the degree of preoperative megacolon present. Megacolon limited to the sigmoid colon was associated with a good outcome in 89.7%, but in only 66.7% with more proximal dilatation (P < 0.05).

CONCLUSION

Occasionally, Hirschsprung's disease presents in adulthood, with ongoing symptoms from early childhood or with the development of functional obstruction, faecal impaction and megacolon in later life. Diagnosis often requires multimodal investigation. A 60 mm full-thickness strip biopsy confirms aganglionosis in 100%. A modified Duhamel procedure is the operation of choice.

Hirschsprung disease and hypoganglionosis in adults: radiologic findings and differentiation

PURPOSE

To retrospectively evaluate the imaging features of adult Hirschsprung disease (HD) and adult hypoganglionosis (HG) and to compare these features with histopathologic findings.

MATERIALS AND METHODS

This study was institutional review board approved, and the requirement for informed consent was waived. The imaging, medical, and histopathologic data of 10 patients (seven women, three men; mean age, 38 years) with histopathologically proved adult HD and/or adult HG were reviewed. Two radiologists reviewed 10 transverse computed tomographic (CT) scans and five double-contrast barium enema radiographs in consensus for the presence or absence and the location of the transition zone. The transverse diameter ratio of the most dilated colonic segment proximal to the transition zone to the narrowed colonic segment distal to the transition zone (ie, transition zone ratio), and the longitudinal length of the transition zone were also determined. The CT findings of HD and HG were compared by using the Mann-Whitney U test.

RESULTS

All patients with lifelong or chronic constipation had a transition zone in the upper part of the rectum or rectosigmoid junction (n = 5) or in the descending colon (n = 5) on the CT scans and the double-contrast barium enema radiographs. The transition zone ratio was significantly different between the patients with HD (median ratio, 4.0) and the patients with HG (median ratio, 2.0) (P = .016). However, there was no significant difference in the longitudinal length of the transition zone between the two patient groups (median ratios, 4.4 cm for HD group and 6.0 cm for HG group; P = .190).

CONCLUSION

A markedly dilated proximal colonic segment with a transition zone and a narrowed distal colonic segment on CT and double-contrast barium enema images in conjunction with chronic refractory constipation in an adult should suggest the diagnosis of adult HD or adult HG. The detection of a much higher transition zone ratio may help to establish the diagnosis of HD.

Hirschsprung's Disease in Adults: Report of a Case and Review of the Literature

Hirschsprung's disease in the adult is a rare and frequently misdiagnosed cause of long-standing refractory constipation. We report a case of Hirschsprung's disease in a 23-year-old man and review the literature. The patient had a history of chronic constipation that required daily enemas, since early infancy, but he had remained in good health until intestinal obstruction developed. As a subemergency operation, right transverse colostomy was performed, to relieve the constipation. Histological examination, by a biopsy, showed absence of ganglion cells in the myenteric plexus in the rectum. One year later, Ikeda's modification of the Duhamel procedure was successfully performed as definitive surgery. The postoperative course was uneventful, and complete resolution of the symptoms without complications has been confirmed by a 22-year follow-up. A review of 229 cases of adult Hirschsprung's disease in the literature suggested that the Duhamel procedure is the operation of choice because of the lower postoperative morbidity rate and better functional outcome.

Diagnosis and outcome of Hirschsprung's disease: does age really matter?

Although Hirschsprung's disease (HD) typically presents in the newborn period, it is often diagnosed in older children, in whom the presentation and management remain poorly defined. We hypothesized that older patients with HD have a milder variant of the disease with an improved prognosis compared with those diagnosed earlier. Children with HD (1995-2001) were divided into Group I (diagnosis before 30 days) and Group II (after 30 days). Patients with total colonic disease were excluded. There were 66 patients; 47 in Group I and 19 in group II. Mean age at diagnosis was 7.1+/-1.3 days (range 1-30 days) versus 27+/-10 months (1.3 months-19 years). Older children differed mainly in the symptoms at presentation and the length of the involved segment of aganglionosis. Surgical strategies were applied equally in both groups. Complications, including postoperative enterocolitis, occurred equally, but the length of stay and costs were lower in Group II. The delayed diagnosis of HD does not worsen outcomes of older children with HD. This finding implies that these children have a milder form of the disease, perhaps because of adaptation to the aganglionic state.