Clinical Outcomes After Staged and Primary Laparotomy Soave Procedure for Total Colonic Aganglionosis: a Single-Center Experience from 2007 to 2017

Evaluation and Management of Total Colonic Hirschsprung Disease: A Comprehensive Review From the American Pediatric Surgical Association (APSA) Hirschsprung Disease Interest Group

BACKGROUND

Children with total colonic Hirschsprung disease (TCHD) are a unique group of patients with pre- and postoperative management challenges. This review provides a rational, expert-based approach to diagnosing and managing TCHD.

METHODS

The guidelines were developed by the Hirschsprung Disease Interest Group members established by the American Pediatric Surgical Association (APSA) Board of Governors. Group discussions, literature review, and expert consensus were used to summarize the current knowledge regarding diagnosis, staged approach, the timing of pull-through, and pre-and postoperative management in children with TCHD.

RESULTS

This paper presents recommendations for managing TCHD before and after reconstruction, including diagnostic criteria, surgical approaches, bowel management, diet, antibiotic prophylaxis, colonic irrigations, and post-surgical considerations.

CONCLUSIONS

A clear understanding of the unique challenges posed by TCHD and consensus on its treatment are lacking in the literature. This review standardizes this patient group's pre- and postoperative management.

LEVEL OF EVIDENCE

V.

Surgical Reconstruction Options for a Case of Near Total Intestinal Aganglionosis

Hirschsprung's disease is a congenital anomaly affecting neural crest cell migration and proliferation in the myenteric plexi resulting in dysmotility, which can present as bilious emesis, delayed meconium passage, and bowel obstruction in neonates, or chronic constipation in older children. Depending on the extent of aganglionosis, this disease can involve the whole gut. Treatment involves a temporary ostomy and interval definitive surgical reconstruction. In patients with near or total intestinal aganglionosis, however, there is no consensus on the most effective surgical reconstruction as consideration of the length and function of the normal remnant bowel create concerns for complications with short bowel syndrome post-operatively. We present a case of near-total intestinal aganglionosis highlighting the various options for definitive surgical reconstruction.

Does Ileocecal Resection Affect Children's Medium-Long-Term Growth and Defecation Patterns? A Matched Case-Control Study

BACKGROUND

Ileocecal resection leads to some early complications, but it is unknown whether it affects children's medium-long-term growth and defecation patterns. To determine if there was an association, we conducted this matched case-control study.

METHODS

This study was conducted in Beijing Children's Hospital and included three groups: the case group (n = 30) included patients with ileocecal duplication undergoing ileocecal resection between January 2010 and June 2021, the control group (n = 90) included outpatient patients without ileocecal resection in January 2022, and the appendectomy group (n = 90) included patients who underwent appendectomy between January 2010 and June 2021. The 1:1 matching criteria included gender and age (within 1 year). The evaluation indicators were growth (height-for-age, BMI) and defecation patterns (stool frequency, stool consistency) over 6 months after surgery. Defecation patterns were assessed in patients older than 4 years. Stool consistency was evaluated by the modified Bristol Stool Form Scale.

RESULTS

There were no significant differences, except for stool consistency, between the case and control groups regarding their growth and defecation patterns before case-control matching. The patients in the case group had a significantly higher prevalence of dry stool (P < 0.008). After case-control matching, there were no significant differences in the growth and defecation patterns between the case and control groups. Before and after case-control matching, there were no significant differences in the defecation patterns between the control group and the appendectomy group.

CONCLUSION

Children's medium-long-term growth and defecation patterns were not affected by ileocecal resection.

Redo pull-through in total colonic aganglionosis due to residual aganglionosis: a single center's experience

BACKGROUND

Reoperation for total colonic aganglionosis (TCA) may be required for residual aganglionosis after an initial radical operation. We aimed to investigate the symptoms, management, and outcomes of patients who required a redo pull-through (Redo PT).

METHODS

Nine TCA patients underwent Redo PT at our center between 2007 and 2017. Their medical records were reviewed. Parental telephone interviews that included disease-specific clinical outcomes were conducted, and post-operative complications and long-term outcomes (including height-for-age/weight-for-age and bowel-function score) were compared to those of single-pull-through (Single PT) patients (n = 21).

RESULTS

All the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment. All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation, indicating residual aganglionosis. The median ages at the initial operation and Redo PT were 200 and 509 days, respectively. Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients. Post-operative complications included perianal excoriation (n = 3), intestinal obstruction (n = 2), enterocolitis (n = 2), and rectovestibular fistula (n = 1). Seven Redo PT patients were followed up for a mean time of 7.1 ± 2.3 years; six (85.7%) had good growth and four (57.1%) had good bowel-function recovery. Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups (all P > 0.05).

CONCLUSION

TCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation. Redo PT is effective and provides good long-term outcomes comparable to those of patients who benefited from Single PT.