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Xu T, Hanke R, Samuk I, Russell TL, Rana MS, Tiusaba L, Jacobs SE, Bokova E, Varda BK, Teeple E, Badillo AT, Levitt MA, Feng C. Treatment of Persistent Soiling in Hirschsprung Disease With Antegrade Continence Enemas. J Surg Res 2024; 302:411-419. [PMID: 39153363 DOI: 10.1016/j.jss.2024.07.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/27/2024] [Accepted: 07/06/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Patients with Hirschsprung disease (HD) can experience soiling after their pull-through. We evaluated the use of antegrade continence enema (ACE) for this patient population and investigated the timing and factors associated with getting the patient clean. METHODS We performed a single-institution retrospective review (from January 2020 to January 2023) of patients with HD and prior pull-through who had persistent soiling, failed laxative treatment or rectal enemas, and were treated with antegrade enemas. The primary outcome was time to become "clean of stool" which was defined as at least one bowel movement per day, no more than one stool accident per week, and no significant stool burden radiographically. Kaplan-Meier survival analysis was performed, and univariate cox proportional hazard regression was used to assess factors associated with time to continence. RESULTS Thirty patients who met the criteria underwent ACE creation at a median age of 6.5 y (interquartile range 5.3-9.8) with a median follow-up time of 11.5 mo (interquartile range 5.6-16.5). Most patients became clean by 4 mo (13 of 20, 65%) with similar results at 1-y follow-up (16 of 21, 76%). The median time to becoming clean was 4.3 mo (95% confidence interval: 1.7-15.0. Patients with hypermotility were more likely to continue to soil at 1 y (80% versus 13%, P = 0.01). There were no additional factors significantly associated with time to cleanliness. CONCLUSIONS ACE is a useful modality for HD patients with soiling. Most became clean of stool in 4 mo. The presence of hypermotility was associated with a higher incidence of persistent soiling at 1 y.
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Affiliation(s)
- Thomas Xu
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia.
| | - Rachel Hanke
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Inbal Samuk
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Teresa L Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Md Sohel Rana
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Shimon E Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Briony K Varda
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Erin Teeple
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Andrea T Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia
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Jevans B, Cooper F, Fatieieva Y, Gogolou A, Kang YN, Restuadi R, Moulding D, Vanden Berghe P, Adameyko I, Thapar N, Andrews PW, De Coppi P, Tsakiridis A, McCann CJ. Human enteric nervous system progenitor transplantation improves functional responses in Hirschsprung disease patient-derived tissue. Gut 2024; 73:1441-1453. [PMID: 38816188 DOI: 10.1136/gutjnl-2023-331532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/07/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE Hirschsprung disease (HSCR) is a severe congenital disorder affecting 1:5000 live births. HSCR results from the failure of enteric nervous system (ENS) progenitors to fully colonise the gastrointestinal tract during embryonic development. This leads to aganglionosis in the distal bowel, resulting in disrupted motor activity and impaired peristalsis. Currently, the only viable treatment option is surgical resection of the aganglionic bowel. However, patients frequently suffer debilitating, lifelong symptoms, with multiple surgical procedures often necessary. Hence, alternative treatment options are crucial. An attractive strategy involves the transplantation of ENS progenitors generated from human pluripotent stem cells (hPSCs). DESIGN ENS progenitors were generated from hPSCs using an accelerated protocol and characterised, in detail, through a combination of single-cell RNA sequencing, protein expression analysis and calcium imaging. We tested ENS progenitors' capacity to integrate and affect functional responses in HSCR colon, after ex vivo transplantation to organotypically cultured patient-derived colonic tissue, using organ bath contractility. RESULTS We found that our protocol consistently gives rise to high yields of a cell population exhibiting transcriptional and functional hallmarks of early ENS progenitors. Following transplantation, hPSC-derived ENS progenitors integrate, migrate and form neurons/glia within explanted human HSCR colon samples. Importantly, the transplanted HSCR tissue displayed significantly increased basal contractile activity and increased responses to electrical stimulation compared with control tissue. CONCLUSION Our findings demonstrate, for the first time, the potential of hPSC-derived ENS progenitors to repopulate and increase functional responses in human HSCR patient colonic tissue.
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Affiliation(s)
- Benjamin Jevans
- Stem Cells and Regenerative Medicine, UCL GOS Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Fay Cooper
- School of Biosciences, The University of Sheffield, Sheffield, UK
- Neuroscience Institute, The University of Sheffield, Sheffield, UK
| | - Yuliia Fatieieva
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Wien, Austria
| | - Antigoni Gogolou
- School of Biosciences, The University of Sheffield, Sheffield, UK
- Neuroscience Institute, The University of Sheffield, Sheffield, UK
| | - Yi-Ning Kang
- Laboratory for Enteric NeuroScience (LENS), Translational Research Centre for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Restuadi Restuadi
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Dale Moulding
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Pieter Vanden Berghe
- Laboratory for Enteric NeuroScience (LENS), Translational Research Centre for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
- Cell and Tissue Imaging Cluster (CIC), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Igor Adameyko
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Wien, Austria
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL GOS Institute of Child Health, London, UK
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital UQ Faculty, South Brisbane, Queensland, Australia
| | - Peter W Andrews
- School of Biosciences, The University of Sheffield, Sheffield, UK
- Neuroscience Institute, The University of Sheffield, Sheffield, UK
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine, UCL GOS Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
| | - Anestis Tsakiridis
- School of Biosciences, The University of Sheffield, Sheffield, UK
- Neuroscience Institute, The University of Sheffield, Sheffield, UK
| | - Conor J McCann
- Stem Cells and Regenerative Medicine, UCL GOS Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
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Noviello C, Romano M, Trotta L, Umano GR, Papparella A. Are the complications after laparo-assisted endo-rectal pull-through for Hirschsprung disease related to the change of the anal tone? LA PEDIATRIA MEDICA E CHIRURGICA 2024; 46. [PMID: 38963345 DOI: 10.4081/pmc.2024.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/09/2024] [Indexed: 07/05/2024] Open
Abstract
The main advantage of the laparo-assisted transanal endorectal pull-through technique (LA - TERPT) for Hirschsprung Disease (HD) is the respect to the rectal-anal anatomy. Postoperative complications have been observed recently. The present study aims to determine how often these postoperative complications occur in these patients. From January 2009 to December 2018, a retrospective analysis was conducted on 36 children (25 males) with HD who underwent LA-TERPT. Data were collected on the age of diagnosis and surgery, sex, the presence of other pathologies, and cases of enterocolitis. In all cases, anorectal manometry (ARM) was performed to evaluate the anal tone. The median age at diagnosis was 2 months and the mean age at surgery was 5 months. Nine related pathologies were identified: five cases of Down syndrome, one case of hypertrophic stenosis of the pylorus, atresia of the esophagus, polydactyly, and anorectal malformation. A patient with total colonic aganglionosis was identified through laparoscopic serummuscular biopsies. Enterocolitis was diagnosed in 7 cases before and 6 after surgery. At follow-up, the complications recorded were: 5 cases of constipation (treated with fecal softeners), one case of anal stenosis (patient with anorectal malformation), 16 cases of soiling (treated with enemas) and 1 child with fecal incontinence (treated with a transanal irrigation system). The ARM was performed in all 36 cases and showed normal anal tone, except for one case with anal hypotonia. LA-TERPT is an important surgical technique for HD. According to the literature, soiling is the most main complication after HD surgery, probably due to "pseudo-incontinence" with normal anal sphincter tone.
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Affiliation(s)
- Carmine Noviello
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
| | - Mercedes Romano
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
| | - Letizia Trotta
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
| | - Giuseppina Rosaria Umano
- Pediatric Unit, Department of Woman, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples.
| | - Alfonso Papparella
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
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Morera C, Nurko S. Hirschsprung's disease. Management. Aliment Pharmacol Ther 2024; 60 Suppl 1:S66-S76. [PMID: 38922939 DOI: 10.1111/apt.18068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/08/2024] [Accepted: 05/15/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Hirschsprung's disease (HD) is a rare congenital disease that is characterised by the absence of ganglion cells in the myenteric plexus starting in the distal bowel. This results in distal functional obstruction and may lead to complications like enterocolitis. The treatment is surgical and requires the resection of the aganglionic segment, and the pull-through of normal intestine into the anal opening. However, even after successful surgery, patients may continue to have symptoms. AIM Discuss current surgical techniques and management strategies for patients with postoperative symptoms after surgical correction of Hirschsprung's disease. METHODS A review of the literature was done through PubMed, with a focus on clinical management and approach. RESULTS We describe the clinical problems that can occur after surgical correction. These include obstructive symptoms, enterocolitis, or faecal incontinence. A systematic approach for the evaluation of these patients includes the exclusion of anatomic, inflammatory, behavioural or motility related factors. Depending on the severity of the symptoms, the evaluation includes examination under anaesthesia, the performance of contrast studies, endoscopic studies, measurement of anal sphincter function and colonic motility studies. The treatment is focused towards addressing the different pathophysiological mechanisms, and may include medical management, botulinum toxin to the anal sphincter or rarely redo-operation. CONCLUSIONS Patients with Hirschsprung's disease need to have surgical correction, and their postoperative long-term management is complex given a variety of associated problems that can occur after surgery. A systematic evaluation is necessary to provide appropriate therapy.
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Affiliation(s)
- Claudio Morera
- Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Boston, Massachusetts, USA
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5
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Fu Y, Gayer C, Gould M, Sicolo AR, Danialifar TF, Van Speybroeck A, Ambartsumyan L, Punati J. Utility of colonic manometry in children with Hirschsprung disease. J Pediatr Gastroenterol Nutr 2024; 78:1217-1224. [PMID: 38682419 DOI: 10.1002/jpn3.12227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 07/23/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Abnormal motility of the residual colon has been reported in post-pull-through Hirschsprung disease (PT-HSCR) patients with persistent defecation problems. We reviewed the role of colonic manometry (CM) in the management of defecation disorders in these patients. METHODS We retrospectively reviewed the medical record of PT-HSCR children who underwent CM for persistent symptoms of abnormal defecation. We reviewed their clinical course and its relation to CM findings. RESULTS Thirty PT-HSCR patients underwent CM, of which five were diagnosed with transition zone pull-through and were excluded. Of the remaining 25 patients, 16 had colonic dysmotility, 8 had normal CM, and one had colonic hypermotility. In patients with dysmotility, five responded to ongoing medical management, three required surgical intervention (ileostomy), three remained symptomatic with medical management but not yet received surgical intervention, and five were lost to follow-up. In patients with normal CM, four responded to ongoing medical therapy, two required additional surgery (antegrade enema procedure), and two were lost to follow-up. The patient with hypermotility improved with adding loperamide. CONCLUSIONS Colonic dysmotility can occur in PT-HSCR patients with persistent defecation problems. CM was helpful in delineating the degree of colonic neuromuscular dysfunction. CM results were used in conjunction with other clinical data to determine optimal management. Our findings support that medical management should first be optimized before consideration of colonic manometry and surgical interventions.
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Affiliation(s)
- Yinan Fu
- Department of Pediatric Gastroenterology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Christopher Gayer
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Michelle Gould
- Department of Pediatric Gastroenterology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Anita R Sicolo
- Department of Pediatric Gastroenterology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Tanaz F Danialifar
- Department of Pediatric Gastroenterology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Lusine Ambartsumyan
- Department of Pediatric Gastroenterology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jaya Punati
- Department of Pediatric Gastroenterology, Children's Hospital Los Angeles, Los Angeles, California, USA
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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Martel RD, Hoyos NA, Tapia-Laliena MÁ, Herrmann I, Herrmann M, Khasanov R, Schäfer KH. Intra-arterial delivery of neurospheres into isolated perfused porcine colons: a proof of concept. Biol Methods Protoc 2024; 9:bpae022. [PMID: 38628556 PMCID: PMC11018533 DOI: 10.1093/biomethods/bpae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/21/2024] [Accepted: 03/30/2024] [Indexed: 04/19/2024] Open
Abstract
Cell replacement in aganglionic intestines is a promising, yet merely experimental tool for the therapy of congenital dysganglionosis of the enteric nervous system like Hirschsprung disease. While the injection of single cells or neurospheres to a defined and very restricted location is trivial, the translation to the clinical application, where large aganglionic or hypoganglionic areas need to be colonized (hundreds of square centimetres), afford a homogeneous distribution of multiple neurospheres all over the affected tissue areas. Reaching the entire aganglionic area in vivo is critical for the restoration of peristaltic function. The latter mainly depends on an intact nervous system that extends throughout the organ. Intra-arterial injection is a common method in cell therapy and may be the key to delivering cells or neurospheres into the capillary bed of the colon with area-wide distribution. We describe an experimental method for monitoring the distribution of a defined number of neurospheres into porcine recta ex vivo, immediately after intra-arterial injection. We designed this method to localize grafting sites of single neurospheres in precise biopsies which can further be examined in explant cultures. The isolated perfused porcine rectum allowed us to continuously monitor the perfusion pressure. A blockage of too many capillaries would lead to an ischaemic situation and an increase of perfusion pressure. Since we could demonstrate that the area-wide delivery of neurospheres did not alter the overall vascular resistance, we showed that the delivery does not significantly impair the local circulation.
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Affiliation(s)
- Richard D Martel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
- Department of Neurophysiology, Mannheim Center for Translational Neurosciences (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Nicolas A Hoyos
- Department of Pediatric Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - María Ángeles Tapia-Laliena
- Department of Pediatric Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Irmgard Herrmann
- Department of Medicine 3, Universitäts-Klinikum Erlangen, Erlangen, Germany
| | - Martin Herrmann
- Department of Pediatric Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
- Department of Medicine 3, Universitäts-Klinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie DZI, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Rasul Khasanov
- Department of Pediatric Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Karl-Herbert Schäfer
- Enteric Nervous System Group, University of Applied Sciences Kaiserslautern, Zweibrücken, Germany
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Irvine WFE, Spivack OKC, Ista E. Moving toward the Development and Effective Implementation of High-Quality Guidelines in Pediatric Surgery: A Review of the Literature. Eur J Pediatr Surg 2024; 34:115-127. [PMID: 38242151 DOI: 10.1055/s-0043-1778020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
Applying evidence-based guidelines can enhance the quality of patient care. While robust guideline development methodology ensures credibility and validity, methodological variations can impact guideline quality. Besides methodological rigor, effective implementation is crucial for achieving improved health outcomes. This review provides an overview of recent literature pertaining to the development and implementation of guidelines in pediatric surgery. Literature was reviewed to provide an overview of sound guideline development methodologies and approaches to promote effective guideline implementation. Challenges specific to pediatric surgery were highlighted. A search was performed to identify published guidelines relevant to pediatric surgery from 2018 to June 2023, and their quality was collectively appraised using the AGREE II instrument. High-quality guideline development can be promoted by using methodologically sound tools such as the Guidelines 2.0 checklist, the GRADE system, and the AGREE II instrument. While implementation can be promoted during guideline development and post-publication, its effectiveness may be influenced by various factors. Challenges pertinent to pediatric surgery, such as limited evidence and difficulties with outcome selection and heterogeneity, may impact guideline quality and effective implementation. Fifteen guidelines were identified and collectively appraised as suboptimal, with a mean overall AGREE II score of 58%, with applicability being the lowest scoring domain. There are identified challenges and barriers to the development and effective implementation of high-quality guidelines in pediatric surgery. It is valuable to prioritize the identification of adapted, innovative methodological strategies and the use of implementation science to understand and achieve effective guideline implementation.
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Affiliation(s)
- Willemijn F E Irvine
- Department of Evidence Based Medicine and Methodology, Qualicura Healthcare Support Agency, Breda, the Netherlands
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Olivia K C Spivack
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nursing Science, Erasmus Medical Center, Rotterdam, the Netherlands
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9
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Wang P, Fang E, Zhao X, Feng J. Nomogram for soiling prediction in postsurgery hirschsprung children: a retrospective study. Int J Surg 2024; 110:1627-1636. [PMID: 38116670 PMCID: PMC10942236 DOI: 10.1097/js9.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE The aim of this study was to develop a nomogram for predicting the probability of postoperative soiling in patients aged greater than 1 year operated for Hirschsprung disease (HSCR). MATERIALS AND METHODS The authors retrospectively analyzed HSCR patients with surgical therapy over 1 year of age from January 2000 and December 2019 at our department. Eligible patients were randomly categorized into the training and validation set at a ratio of 7:3. By integrating the least absolute shrinkage and selection operator [LASSO] and multivariable logistic regression analysis, crucial variables were determined for establishment of the nomogram. And, the performance of nomogram was evaluated by C-index, area under the receiver operating characteristic curve, calibration curves, and decision curve analysis. Meanwhile, a validation set was used to further assess the model. RESULTS This study enrolled 601 cases, and 97 patients suffered from soiling. Three risk factors, including surgical history, length of removed bowel, and surgical procedures were identified as predictive factors for soiling occurrence. The C-index was 0.871 (95% CI: 0.821-0.921) in the training set and 0.878 (95% CI: 0.811-0.945) in the validation set, respectively. And, the AUC was found to be 0.896 (95% CI: 0.855-0.929) in the training set and 0.866 (95% CI: 0.767-0.920) in the validation set. Additionally, the calibration curves displayed a favorable agreement between the nomogram model and actual observations. The decision curve analysis revealed that employing the nomogram to predict the risk of soiling occurrence would be advantageous if the threshold was between 1 and 73% in the training set and 3-69% in the validation set. CONCLUSION This study represents the first efforts to develop and validate a model capable of predicting the postoperative risk of soiling in patients aged greater than 1 year operated for HSCR. This model may assist clinicians in determining the individual risk of soiling subsequent to HSCR surgery, aiding in personalized patient care and management.
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Affiliation(s)
| | | | | | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology; Hubei Clinical Center of Hirschsprung Disease and Allied Disorders, Wuhan, People’s Republic of China
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10
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Montalva L, Cheng LS, Kapur R, Langer JC, Berrebi D, Kyrklund K, Pakarinen M, de Blaauw I, Bonnard A, Gosain A. Hirschsprung disease. Nat Rev Dis Primers 2023; 9:54. [PMID: 37828049 DOI: 10.1038/s41572-023-00465-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/14/2023]
Abstract
Hirschsprung disease (HSCR) is a rare congenital intestinal disease that occurs in 1 in 5,000 live births. HSCR is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the intestine. Most patients present during the neonatal period with the first meconium passage delayed beyond 24 h, abdominal distension and vomiting. Syndromes associated with HSCR include trisomy 21, Mowat-Wilson syndrome, congenital central hypoventilation syndrome, Shah-Waardenburg syndrome and cartilage-hair hypoplasia. Multiple putative genes are involved in familial and isolated HSCR, of which the most common are the RET proto-oncogene and EDNRB. Diagnosis consists of visualization of a transition zone on contrast enema and confirmation via rectal biopsy. HSCR is typically managed by surgical removal of the aganglionic bowel and reconstruction of the intestinal tract by connecting the normally innervated bowel down to the anus while preserving normal sphincter function. Several procedures, namely Swenson, Soave and Duhamel procedures, can be undertaken and may include a laparoscopically assisted approach. Short-term and long-term comorbidities include persistent obstructive symptoms, enterocolitis and soiling. Continued research and innovation to better understand disease mechanisms holds promise for developing novel techniques for diagnosis and therapy, and improving outcomes in patients.
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Affiliation(s)
- Louise Montalva
- Department of Paediatric Surgery, Robert-Debré Children's University Hospital, Paris, France.
- Faculty of Health, Paris-Cité University, Paris, France.
- NeuroDiderot, INSERM UMR1141, Paris, France.
| | - Lily S Cheng
- Division of Paediatric Surgery, Texas Children's Hospital, Houston, TX, USA
- Division of Paediatric Surgery, University of Virginia, Charlottesville, VA, USA
| | - Raj Kapur
- Department of Pathology, Seattle Children's Hospital, Seattle, WA, USA
| | - Jacob C Langer
- Division of Paediatric Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dominique Berrebi
- Department of Pathology, Robert-Debré and Necker Children's University Hospital, Paris, France
| | - Kristiina Kyrklund
- Department of Paediatric Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Mikko Pakarinen
- Department of Paediatric Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Ivo de Blaauw
- Department of Surgery, Division of Paediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, Netherlands
| | - Arnaud Bonnard
- Department of Paediatric Surgery, Robert-Debré Children's University Hospital, Paris, France
- Faculty of Health, Paris-Cité University, Paris, France
- NeuroDiderot, INSERM UMR1141, Paris, France
| | - Ankush Gosain
- Department of Paediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.
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11
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Bokova E, Prasade N, Janumpally S, Rosen JM, Lim IIP, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Hirschsprung Disease. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1418. [PMID: 37628417 PMCID: PMC10453740 DOI: 10.3390/children10081418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
After an initial pull-though, patients with Hirschsprung disease (HD) can present with obstructive symptoms, Hirschsprung-associated enterocolitis (HAEC), failure to thrive, or fecal soiling. This current review focuses on algorithms for evaluation and treatment in children with HD as a part of a manuscript series on updates in bowel management. In constipated patients, anatomic causes of obstruction should be excluded. Once anatomy is confirmed to be normal, laxatives, fiber, osmotic laxatives, or mechanical management can be utilized. Botulinum toxin injections are performed in all patients with HD before age five because of the nonrelaxing sphincters that they learn to overcome with increased age. Children with a patulous anus due to iatrogenic damage of the anal sphincters are offered sphincter reconstruction. Hypermotility is managed with antidiarrheals and small-volume enemas. Family education is crucial for the early detection of HAEC and for performing at-home rectal irrigations.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
| | - Ninad Prasade
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
| | - Sanjana Janumpally
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
| | - John M. Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Irene Isabel P. Lim
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children’s National Medical Center, Washington, DC 20001, USA
| | - Rebecca M. Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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12
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Bischoff A, Hayes K, Guimaraes C, Merritt A, Wickham M, Schneider L, Martin H, Ketzer J, Rodriguez V, Peña A, De La Torre L. Standardization of radiograph readings during bowel management week. Pediatr Surg Int 2023; 39:236. [PMID: 37468717 DOI: 10.1007/s00383-023-05513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION During "bowel management week," abdominal radiographs are used to monitor the amount and location of stool. A radiologist familiar with the treatment plan can provide an improved interpretation. The goal of this paper is to standardize the radiological reports during a bowel management week. METHODS We saw 744 patients during bowel management week from May 2016 until March 2023. Diagnosis included: anorectal malformation (397), idiopathic constipation (180), Hirschsprung disease (89), and spina bifida (78). Laxatives were the treatment for 51% of patients, and 49% received enemas. Characteristic radiographs were selected for each treatment group for a proposed reading standardization. RESULTS When the stool is visualized, it is crucial to report its location. Having a contrast enema helps with the correct interpretation of the colonic anatomy. It is also essential to always compare the amount of stool with the radiograph from the previous day to determine if there is an increase or decrease in stool. Examples of radiographs are shown to guide the use of the preferred proposed terminology. CONCLUSION Providing information regarding which treatment modality the patient is receiving and stating that a patient is on a bowel management week treatment is crucial for the radiologist to provide adequate interpretation. The radiologist must be familiar with the treatment goals and purpose of the daily radiograph.
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Affiliation(s)
- A Bischoff
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA.
| | - K Hayes
- Department of Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - C Guimaraes
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - A Merritt
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - M Wickham
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - L Schneider
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - H Martin
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - J Ketzer
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - V Rodriguez
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - A Peña
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - L De La Torre
- Department of Pediatric Surgery, International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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13
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Ambartsumyan L, Patel D, Kapavarapu P, Medina-Centeno RA, El-Chammas K, Khlevner J, Levitt M, Darbari A. Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr 2023; 76:533-546. [PMID: 36720091 DOI: 10.1097/mpg.0000000000003717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Children with Hirschsprung disease have postoperative long-term sequelae in defecation that contribute to morbidity and mortality and significantly impact their quality of life. Pediatric patients experience ongoing long-term defecation concerns, which can include fecal incontinence (FI) and postoperative obstructive symptoms, such as constipation and Hirschsprung-associated enterocolitis. The American Pediatric Surgical Association has developed guidelines for management of these postoperative obstructive symptoms and FI. However, the evaluation and management of patients with postoperative defecation problems varies among different pediatric gastroenterology centers. This position paper from the Neurogastroenterology & Motility Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviews the current evidence and provides suggestions for the evaluation and management of postoperative patients with Hirschsprung disease who present with persistent defecation problems.
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Affiliation(s)
- Lusine Ambartsumyan
- From the Division of Gastroenterology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Dhiren Patel
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St Louis, MO
| | - Prasanna Kapavarapu
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ricardo A Medina-Centeno
- the Division of Gastroenterology, Hepatology and Nutrition, Phoenix Children's, College of Medicine, University of Arizona, Tucson, AZ
| | - Khalil El-Chammas
- the Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julie Khlevner
- the Division of Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Marc Levitt
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
| | - Anil Darbari
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
- the Division of Gastroenterology and Nutrition, Children's National Hospital, Washington, DC
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14
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Bokova E, McKenna E, Krois W, Reck CA, Al-Shamaileh T, Jacobs SE, Tiusaba L, Russell TL, Darbari A, Feng C, Badillo AT, Levitt MA. Reconstructing the anal sphincters to reverse iatrogenic overstretching following a pull-through for Hirschsprung disease. One-year outcomes. J Pediatr Surg 2023; 58:484-489. [PMID: 36470689 DOI: 10.1016/j.jpedsurg.2022.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with Hirschsprung disease (HSCR), soiling may be related to anal sphincter damage following the initial pull-through. No optimal treatment has been developed for such patients, although enemas (rectal or antegrade) have been applied with some success. We present the one-year outcomes of a new technique for anal sphincter reconstruction. METHODS All patients with HSCR referred from other institutions for post pull-through soiling were studied. Seven patients with patulous sphincters underwent sphincter reconstruction. Six had a full preoperative evaluation and were included in the study. Their 12-month outcomes were assessed. RESULTS All six patients had soiling without voluntary bowel movements (VBMs). One patient was clean on Malone flushes when referred. Three underwent pre- and post-reconstruction non-sedated three-dimensional anorectal manometry, and objectively were able to close their sphincters following the reconstruction. All patients without Down syndrome (4 of 6) showed improvement in the abbreviated Baylor Continence Scale (4.5 vs. 0.75). One patient has achieved total bowel control without antegrade flushes, three now have VBMs which they did not have before but have occasional accidents and use antegrade flushes intermittently. They reported higher productivity, the ability to participate in sports and be away from home with confidence in their regimen. Two of 6 patients have Down syndrome and required a redo pull-through for other indications and underwent empiric sphincter reconstruction. For these two patients we do not have an outcomes assessment. CONCLUSIONS A new technique for sphincter reconstruction shows promising results in improvement of bowel control at one year. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA.
| | - Elise McKenna
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Wilfried Krois
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Carlos A Reck
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Tamador Al-Shamaileh
- Department of General Surgery, Faculty of Medicine, Mu'tah University, Kerak, Jordan
| | - Shimon E Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Teresa L Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Anil Darbari
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Andrea T Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
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15
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Lu C, Pan S, Hua X, Jiang W, Tang W. Bowel function at preschool and early childhood age in children with long-segment Hirschsprung disease. Eur J Pediatr 2023; 182:1251-1259. [PMID: 36633657 DOI: 10.1007/s00431-023-04814-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
Bowel dysfunction has been proven to be the most typical complication of long-segment Hirschsprung disease (LSHD). Additionally, bowel dysfunction in preschool and early childhood should be properly assessed, because it may result in persistent bowel dysfunction, social issues, and depression in adolescence and adulthood. This study evaluated bowel function during preschool and early childhood in patients with LSHD. A cross-sectional bowel function score (BFS) questionnaire survey was conducted on 270 infants with short-segment Hirschsprung disease (SSHD) and LSHD who underwent pull-through (PT) between January 2014 and December 2019 at the Children's Hospital of Nanjing Medical University. One hundred ninety patients who consented to the survey were asked to complete the questionnaire and were divided into two groups: the LSHD group (n = 42) and the SSHD group (n = 148). Bowel function outcomes were assessed by using a questionnaire. The total BFS score in the LSHD group was significantly lower than that in the SSHD group (15.0 [14.0, 17.0] vs. 18.0 [16.0, 19.0], p < 0.05) and did not improve with age (p > 0.05). Independent BFS items with lower scores were discovered in LSHD than in SSHD, including the capacity to hold back defecation, feeling/reporting the urge to defecate, frequency, soiling, and accidents (all p < 0.05). After subgroup analysis of follow-up age (3-5 years, 5 ~ 7 years, and > 7 years), there was no difference between the score of ability to hold back defecation over 7 years old and feeling/reporting the urge to defecate over 5 years old (all p > 0.05). The frequency and soiling scores were lower in the LSHD group than in the SSHD group over 5 years of age (all p < 0.05). Fortunately, there was no difference in constipation scores and social problems between the LSHD and SSHD groups in every sub-follow-up group (all p > 0.05). Conclusion: Overall, bowel function at preschool and early childhood age was poorer in LSHD than in SSHD and did not improve with age. However, the ability to hold back defecation and feeling/reporting the urge to defecate with age in LSHD may be similar to those in SSHD. Simultaneously, the frequency, soiling, and number of accidents were consistently worse in the LSHD group. Trial registration: This study was retrospectively registered in the ClinicalTrials database.gov (NCT05461924) in August 2022. What is Known: • Bowel function in SSHD is satisfactory or near-normal, and the general consensus is that the longer the aganglionic segment, the worse the bowel function after surgery. • Bowel functional outcomes of LSHD were not defined, and the limited reports of bowel functional outcomes compared with SSHD were extensively varied. Bowel dysfunction at preschool and early childhood may lead to persistent bowel dysfunction, social problems, and depression in adolescence or adulthood. What is New: • Bowel function in preschool and early childhood in patients with LSHD has not been defined and should be thoroughly assessed in a larger group of patients with precise definitions of incontinence or soiling. • The present study was primarily designed to evaluate bowel function at preschool and early childhood age in LSHD compared with SSHD in a relatively large number of HD cases using BFS.
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Affiliation(s)
- Changgui Lu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Shiwen Pan
- Department of Anesthesia and Operation, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Xinyi Hua
- Nanjing Medical University, Nanjing, 210008, China
| | - Weiwei Jiang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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16
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Abstract
Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.
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Affiliation(s)
- Hira Ahmad
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.
| | - Donald B Shaul
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, California; Voluntary Associate Professor of Surgery, University of California, Irvine, USA
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17
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Systematic appraisal of the guidelines for the diagnosis and treatment of Hirschsprung's disease. Pediatr Surg Int 2022; 38:1197-1208. [PMID: 35867125 DOI: 10.1007/s00383-022-05151-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Some guidelines for management of Hirschsprung's disease (HSCR, HD) have been developed, but their quality is vague. This study will systematically assess the quality of guidelines and analyze the key recommendations and the best evidence for guidelines. METHODS Applicable guidelines were retrieved using a systematic search of databases. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess the quality of the guidelines. Then, the recommendations and evidence for the included guidelines were extracted and compared. RESULTS A total of nine guidelines were included in this study, and only one had an overall standardized score of more than 60%, indicating that it is worthy of recommendation. The problems identified included ambiguous and low-quality evidence; obvious distributional heterogeneity among the recommendations; a lack of in-depth discussion on the interpretation of staging, diagnostic methods, conservative treatment, and surgical staging of disease. CONCLUSION The quality of guidelines varies widely, and there is a lack of high-quality professional opinions and supporting evidence for the main recommendations. At present, only comprehensive guidelines can be considered high-quality and there is still room for improvement.
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18
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Ahmad H, Yacob D, Halleran DR, Gasior AC, Lorenzo CD, Wood RJ, Langer JC, Levitt MA. Evaluation and treatment of the post pull-through Hirschsprung patient who is not doing well; Update for 2022. Semin Pediatr Surg 2022; 31:151164. [PMID: 35690463 DOI: 10.1016/j.sempedsurg.2022.151164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
After operative intervention for Hirschsprung disease (HD) a child should thrive, be fecally continent, and avoid recurrent episodes of abdominal distention and enterocolitis. This is unfortunately not the case for a significant number of patients who struggle following their pull-through procedure. Many clinicians are puzzled by these outcomes as they can occur in patients who they believe have had a technically satisfactory described operation. This review presents an organized approach to the evaluation and treatment of the post HD pull-through patient who is not doing well. Patients with HD who have problems after their initial operation can have: (1) fecal incontinence, (2) obstructive symptoms, and (3) recurrent episodes of enterocolitis (a more severe subset of obstructive symptoms). After employing a systematic diagnostic approach, successful treatments can be implemented in almost every case. Patients may need medical management (behavioral interventions, dietary changes, laxatives, or mechanical emptying of the colon), a reoperation when a specific anatomic or pathologic cause is identified, or botulinum toxin when non-relaxing sphincters are the cause of the obstructive symptoms or recurrent enterocolitis.
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Affiliation(s)
- Hira Ahmad
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - Desale Yacob
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, United States
| | - Devin R Halleran
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Alessandra C Gasior
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Carlo Di Lorenzo
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, United States
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Canada
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC, United States.
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19
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Short SS, Durham MM, Rollins MD. Hirschsprung disease outcomes. Semin Pediatr Surg 2022; 31:151160. [PMID: 35690462 DOI: 10.1016/j.sempedsurg.2022.151160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hirschsprung disease (HD) is a complex surgical and medical problem that appears to have varied health and social outcomes with the age and neurodevelopmental state of patients. In general, long-term outcomes are thought to be good for the majority of patients despite recognized problems with constipation and/or fecal incontinence. However, there are no universally accepted pathways regarding post-operative bowel management programs nor clearly defined follow-up pathways making the current outcome measures difficult to interpret. Further, other factors that may influence outcome including age at the time of procedure and procedure type continue to lack consensus. Improved support of children in resource limited environments and during periods of transition into the adult medical care environment are needed to improve outcome. Recent proliferation of multidisciplinary care teams and consortia may help to better understand outcomes and address current knowledge gaps. Continuing these collaborations will be imperative to continuing improvements in care which may ultimately impact outcome.
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Affiliation(s)
- Scott S Short
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84113, United States.
| | - Megan M Durham
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Room B206 1364 Clifton Road, NE, Atlanta, GA 30322, Georgia
| | - Michael D Rollins
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84113, United States
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20
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Arbizu R, Freiberg B, Rodriguez L. Lower Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1255-1271. [PMID: 34736588 DOI: 10.1016/j.pcl.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Functional and motility gastrointestinal disorders are the most common complaints to the pediatric gastroenterologist. Disorders affecting the small intestine carry a significant morbidity and mortality due to the severe limitation of therapeutic interventions available and the complications associated with such interventions. Congenital colorectal disorders are rare but also carry significant morbidity and poor quality of life plus the social stigma associated with its complications. In this review, we summarize the clinical presentation, diagnostic evaluations, and the therapeutic interventions available for the most common and severe gastrointestinal functional and motility disorders of the small bowel, colon, and anorectum.
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Affiliation(s)
- Ricardo Arbizu
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA
| | - Ben Freiberg
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Gastroenterology and Hepatology, Neurogastroenterology and Motility Center, Yale School of Medicine, Yale University School of Medicine, Yale New Haven Children's Hospital, 333 Cedar Street, LMP 4093, PO Box 208064, New Haven, CT 06520, USA.
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21
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Ahmad H, Levitt MA, Yacob D, Halleran DR, Gasior AC, Di Lorenzo C, Wood RJ, Langer JC. Evaluation and Management of Persistent Problems After Surgery for Hirschsprung Disease in a Child. Curr Gastroenterol Rep 2021; 23:18. [PMID: 34633517 DOI: 10.1007/s11894-021-00819-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Ideally, after operative intervention, a child born with Hirschsprung disease (HD) should thrive, achieve fecal continence, and avoid recurrent episodes of abdominal distention and enterocolitis. However, a significant number of patients continue to struggle following their pull-through procedure. The purpose of this review is to present an organized and practical approach to the evaluation and management of the symptomatic patient post pull-through operation for HD. RECENT FINDINGS Children diagnosed with HD who are not doing well after their initial operation can be categorized in three distinct groups: (1) those that have fecal incontinence, (2) those with obstructive symptoms, and (3) those with recurrent episodes of enterocolitis. It is important to have a systematic diagnostic approach for these patients based on a comprehensive protocol. All three of these patient groups can be treated with a combination of either medical management, reoperation when a specific anatomic or pathologic etiology is identified, or botulinum toxin for non-relaxing sphincters contributing to the obstructive symptoms or recurrent enterocolitis. For patients not doing well after their initial pull-through, a systematic workup should be employed to determine the etiology. Once identified, a multidisciplinary and organized approach to management of the symptomatic patients can alleviate most post pull-through symptoms.
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Affiliation(s)
- Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc A Levitt
- Children's National Colorectal Center, Division of Colorectal and Pelvic Reconstructive Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Desale Yacob
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Devin R Halleran
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alessandra C Gasior
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Colorectal Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Canada.
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Chanpong A, Borrelli O, Thapar N. Hirschsprung disease and Paediatric Intestinal Pseudo-obstruction. Best Pract Res Clin Gastroenterol 2021; 56-57:101765. [PMID: 35331399 DOI: 10.1016/j.bpg.2021.101765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 01/31/2023]
Abstract
Hirschsprung disease (HSCR) and Paediatric Intestinal Pseudo-obstruction (PIPO) comprise two of the most recognized and severe disorders of gastrointestinal (GI) motility. HSCR is a developmental disorder of the enteric nervous system invariably affecting the large intestine, whereas the majority of PIPO conditions represent congenital disorders of one or more components of the neuromusculature and more diffusely affect the GI tract. Histopathology is deemed the gold standard for the diagnosis of HSCR and, arguably, of PIPO, but, other diagnostic modalities such as manometric and genetic studies have seen recent advances that may increase their utility. Especially for PIPO, management is multidisciplinary and best performed in specialist referral centres. Surgery remains the only viable treatment for HSCR and appears essential to optimize and sustain feeding and viability of intestinal function in PIPO patients. Novel therapies such as neural stem cell transplants show promise for the future.
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Affiliation(s)
- Atchariya Chanpong
- Neurogastroenterology & Motility Unit, Gastroenterology Department, Great Ormond Street Hospital for Children, London, WC1N 3JH, United Kingdom; Division of Gastroenterology and Hepatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand; Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, United Kingdom
| | - Osvaldo Borrelli
- Neurogastroenterology & Motility Unit, Gastroenterology Department, Great Ormond Street Hospital for Children, London, WC1N 3JH, United Kingdom
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, United Kingdom; Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Queensland, 4101, Australia.
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23
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Telborn L, Tofft L, Kristensson Hallström I, Waldenvik F, Axelsson I, Stenström P. Diet plays a central role in parental self-treatment of children with Hirschsprung's disease-a qualitative study. Acta Paediatr 2021; 110:2610-2617. [PMID: 34032316 DOI: 10.1111/apa.15952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/16/2021] [Accepted: 05/21/2021] [Indexed: 11/28/2022]
Abstract
AIM Hirschsprung's disease is a congenital disorder requiring surgery. Most children operated on for Hirschsprung's disease experience postoperative bowel dysmotility. Although various food is known to influence bowel motility, evidence of diet's role and dietary guidelines in treatment of bowel dysfunction in Hirschsprung's disease is lacking. The aim was to explore parental experiences of dietary effects on bowel function in children with Hirschsprung's disease. METHODS A qualitative study including three focus groups with ten parents of children with Hirschsprung's disease at a national Hirschsprung's disease centre. Data were analysed through content analysis. RESULTS Parents emphasised diet as a strong influencer on their child's bowel function in Hirschsprung's disease. They expressed great concerns about their responsibility and strived hard to explore and adjust dietary habits to control the child's bowel function. Families' daily and social lives were influenced by the child's diet and bowel function. The parents desired dietary support and guidelines to improve their confidence in self-treatment of Hirschsprung's disease. CONCLUSION Dietary habits play a key role in parental self-treatment of bowel function in their children with Hirschsprung's disease. Dietary guidelines for patients with Hirschsprung's disease are anticipated.
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Affiliation(s)
- Lovisa Telborn
- Department of Paediatric Surgery Skåne University Hospital Lund Sweden
- Department of Clinical Sciences, Paediatrics Lund University Lund Sweden
| | - Louise Tofft
- Department of Paediatric Surgery Skåne University Hospital Lund Sweden
- Department of Clinical Sciences, Paediatrics Lund University Lund Sweden
| | | | - Frida Waldenvik
- Department of Paediatrics Skåne University Hospital Lund Sweden
| | - Irene Axelsson
- Department of Clinical Sciences, Paediatrics Lund University Lund Sweden
- Department of Paediatrics Skåne University Hospital Lund Sweden
| | - Pernilla Stenström
- Department of Paediatric Surgery Skåne University Hospital Lund Sweden
- Department of Clinical Sciences, Paediatrics Lund University Lund Sweden
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24
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Verkuijl SJ, Friedmacher F, Harter PN, Rolle U, Broens PMA. Persistent bowel dysfunction after surgery for Hirschsprung’s disease: A neuropathological perspective. World J Gastrointest Surg 2021; 13:822-833. [PMID: 34512906 PMCID: PMC8394380 DOI: 10.4240/wjgs.v13.i8.822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/12/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Hirschsprung’s disease (HD) is a congenital disorder, characterized by aganglionosis in the distal part of the gastrointestinal tract. Despite complete surgical resection of the aganglionic segment, both constipation and fecal incontinence persist in a considerable number of patients with limited treatment options. There is growing evidence for structural abnormalities in the ganglionic bowel proximal to the aganglionosis in both humans and animals with HD, which may play a role in persistent bowel dysfunction. These abnormalities include: (1) Histopathological abnormalities of enteric neural cells; (2) Imbalanced expression of neurotransmitters and neuroproteins; (3) Abnormal expression of enteric pacemaker cells; (4) Abnormalities of smooth muscle cells; and (5) Abnormalities within the extracellular matrix. Hence, a better understanding of these previously unrecognized neuropathological abnormalities may improve follow-up and treatment in patients with HD suffering from persistent bowel dysfunction following surgical correction. In the long term, further combination of clinical and neuropathological data will hopefully enable a translational step towards more individual treatment for HD.
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Affiliation(s)
- Sanne J Verkuijl
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt 60590, Germany
- Neurological Institute (Edinger-Institute), University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt 60528, Germany
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen 9700 RB, Netherlands
| | - Florian Friedmacher
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt 60590, Germany
| | - Patrick N Harter
- Neurological Institute (Edinger-Institute), University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt 60528, Germany
| | - Udo Rolle
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt 60590, Germany
| | - Paul MA Broens
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen 9700 RB, Netherlands
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25
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Demehri FR, Dickie BH. Reoperative techniques and management in Hirschsprung disease: a narrative review. Transl Gastroenterol Hepatol 2021; 6:42. [PMID: 34423163 DOI: 10.21037/tgh-20-224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/12/2020] [Indexed: 11/06/2022] Open
Abstract
The majority of children who undergo operative management for Hirschsprung disease have favorable results. A subset of patients, however, have long-term dysfunctional stooling, characterized by either frequent soiling or obstructive symptoms. The evaluation and management of a child with poor function after pull-through for Hirschsprung disease should be conducted by an experienced multidisciplinary team. A systematic workup is focused on detecting pathologic and anatomic causes of pull-through dysfunction. This includes an exam under anesthesia, pathologic confirmation including a repeat biopsy, and a contrast enema, with additional studies depending on the suspected etiology. Obstructive symptoms may be due to technique-specific types of mechanical obstruction, histopathologic obstruction, or dysmotility-each of which may benefit from reoperative surgery. The causes of soiling symptoms include loss of the dentate line and damage to the anal sphincter, which generally do not benefit from revision of the pull-through, and pseudo-incontinence, which may reveal underlying obstruction. A thorough understanding of the types of complications associated with various pull-through techniques aids in the evaluation of a child with postoperative dysfunction. Treatment is specifically tailored to the patient, guided by the etiology of the patient's symptoms, with options ranging from bowel management to redo pull-through procedure. This review details the workup and management of patients with complications after pull-through, with a focus on the perioperative management and technical considerations for those who require reoperation.
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Affiliation(s)
- Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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26
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Pecoraro AR, Hunter CE, Bennett WE, Markel TA. Factors Affecting Higher Readmission Rates and Costs in Pediatric Patients With Hirschsprung Disease. J Surg Res 2021; 268:291-299. [PMID: 34392183 DOI: 10.1016/j.jss.2021.06.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hirschsprung disease is a relatively uncommon disorder of the developing gastrointestinal tract that requires surgical intervention to restore long-term function. While readmission for Hirschsprung-related complications is a known concern in these patients, we sought to identify patient-level factors associated with a prolonged hospital stay, increased costs at the time of a pull-through operation, as well as the risk for all-cause inpatient readmission after surgery. We hypothesized that higher level of care requirement during the operative stay, age at operation, and length of stay (LOS) would portend increased readmissions and disease-related complications such as Hirschsprung-associated enterocolitis. METHODS Data was obtained from the Pediatric Health Information System database on all Hirschprung patients who underwent a pull-through operation between 2004 and 2019. Regression analyses were performed on this cohort of 3345 patients. Multivariable regression models were utilized to analyze the key outcome variables of postoperative LOS and adjusted charges. RESULTS Post-operative LOS was significantly increased by the presence of a surgical complication, congenital/genetic defect, or neurologic/neuromuscular defect. Increased LOS was also seen in Black patients. The cost of pull-through operations was significantly higher in patients admitted to the NICU and ICU during index hospitalization, with a cost increase of approximately $75,000 and $57,000 respectively. Presence of a surgical complication, comorbid congenital/genetic defect, and need for mechanical ventilation were associated with higher odds of inpatient readmission. CONCLUSION The management of patients with Hirschsprung disease is longitudinal and complex. Identification of key patient metrics can aid clinicians in developing targeted care and education strategies to minimize readmission and excessive hospital charges.
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Affiliation(s)
- Anthony R Pecoraro
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Chelsea E Hunter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - William E Bennett
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Troy A Markel
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indianapolis.
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27
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Krois W, Reck CA, Darbari A, Badillo A, Levitt MA. A technique to reconstruct the anal sphincters following iatrogenic stretching related to a pull-through for Hirschsprung disease. J Pediatr Surg 2021; 56:1242-1246. [PMID: 33358008 DOI: 10.1016/j.jpedsurg.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 12/29/2022]
Abstract
Soiling and fecal incontinence are troubling complications which can occur after a pull-through for Hirschsprung disease. They can usually be improved with proper medical management, but in some cases are the result of an anatomic defect related to overstretching of the sphincters and/or damage of the anal canal. For such patients the treatment of this true fecal incontinence is limited to a structured bowel management program with ante- or retrograde enemas to achieve social continence. Herein we report two such patients with overstretched sphincters and loss of the dentate line after an initial pull-through and describe a sphincter tightening technique to improve bowel control.
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Affiliation(s)
- Wilfried Krois
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria.
| | - Carlos A Reck
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Anil Darbari
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, USA
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, USA
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28
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Chan KWE, Lee KH, Wong HYV, Tsui SYB, Mou JWC, Tam YHP. Long-Term Results of One-Stage Laparoscopic-Assisted Endorectal Pull-Through for Rectosigmoid Hirschsprung's Disease in Patients Aged Above 5 Years. J Laparoendosc Adv Surg Tech A 2020; 31:225-229. [PMID: 33198556 DOI: 10.1089/lap.2020.0549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Despite the fact that the laparoscopic-assisted endorectal pull-through (LAEPT) for Hirschsprung's disease (HD) was introduced over 20 years ago, published outcomes in older children and adolescent are lacking. To address this, we studied the long-term results of LATEP for rectosigmoid HD in patients above 5 years of age. Materials and Methods: A retrospective review was conducted on all nonsyndromic patients above 5 years of age and who underwent one-stage LAEPT for rectosigmoid HD between January 2002 and December 2017. Late Hirschsprung-associated enterocolitis (HAEC) was defined as HAEC occurring 1 year after the pull-through operation. Postoperative bowel function was assessed using the Krickenbeck classification. Results: Forty-one patients (37 males and 4 females) were included in this study with a median follow-up of 9.0 years. The median age at surgery was 55 days. Two patients had anastomotic leakage. No patient had late HAEC, rectal prolapse, anastomotic stricture, or intestinal obstruction. According to the Krickenbeck classification, all patients had voluntary bowel movements without constipation. Overall, 65.8% of patients had no soiling. However, on subgroup analysis, only 45.4% of patients younger than 11 years of age had no soiling compared with 89.5% in patients at or older than 11 years of age (P = .003). Conclusions: Our results showed that LAEPT for rectosigmoid HD was a safe procedure. Nearly 90% of patients had normal bowel function by puberty. Further studies are needed to address the problem of soiling in patients younger than 11 years of age.
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Affiliation(s)
- Kin Wai Edwin Chan
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kim Hung Lee
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hei Yi Vicky Wong
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Siu Yan Bess Tsui
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jennifer Wai Cheung Mou
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuk Him Peter Tam
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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29
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Hutson J. Letter to the Editor regarding: Guidelines for the management of postoperative soiling in children with Hirschsprung disease, Saadai et al. PSI (2019)35: 829-834. Pediatr Surg Int 2020; 36:753. [PMID: 31612339 DOI: 10.1007/s00383-019-04556-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2019] [Indexed: 10/25/2022]
Affiliation(s)
- John Hutson
- Urology Department, The Royal Children's Hospital, Parkville, VIC, Australia. .,Department of Paediatrics, University of Melbourne, Melbourne, Australia. .,Surgical Group, Murdoch Children's Research Institute, Melbourne, Australia.
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