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Current understanding of Hirschsprung-associated enterocolitis: Pathogenesis, diagnosis and treatment. Semin Pediatr Surg 2022; 31:151162. [PMID: 35690459 PMCID: PMC9523686 DOI: 10.1016/j.sempedsurg.2022.151162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hirschsprung-associated enterocolitis (HAEC) was described in 1886 by Harald Hirschsprung and is a potentially deadly complication of Hirschsprung Disease. HAEC is classically characterized by abdominal distension, fever, and diarrhea, although there can be a variety of other associated symptoms, including colicky abdominal pain, lethargy, and the passage of blood-stained stools. HAEC occurs both pre-operatively and post-operatively, is the presenting symptom of HSCR in up to 25% of infants and varies in overall incidence from 20 to 60%. This article reviews our current understanding of HAEC pathogenesis, diagnosis, and treatment with discussion of areas of ongoing research, controversy, and future investigation.
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Mohamed W, Elsawaf MI, Shalaby AI, Arafat AE, Marei MM, Aboulfadl MH, Kaddah SN, El Tagy GH, Bahaaeldin KHK. Optimism for the Single-stage Transanal Swenson in Neonates. J Indian Assoc Pediatr Surg 2021; 26:16-22. [PMID: 33953507 PMCID: PMC8074829 DOI: 10.4103/jiaps.jiaps_187_19] [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: 10/18/2019] [Revised: 12/14/2019] [Accepted: 05/08/2020] [Indexed: 11/04/2022] Open
Abstract
Background Hirschsprung's disease (HD) has been traditionally treated from infancy onward and different techniques have been used including Swenson, Soave, and Duhamel procedures. The purpose of this study was to evaluate the transanal Swenson's procedure for classical rectosigmoid HD in neonates. Patient and Methods This was a prospective study in which neonates diagnosed with HD were recruited from January 2017 to December 2018. Cases with a transition zone proximal to the midsigmoid were excluded. All patients underwent a transanal Swenson's procedure in the neonatal period using a unified protocol. Intraoperative course and postoperative outcomes such as leak, pelvic abscess, soiling, perianal excoriation, stricture, enterocolitis, and constipation were evaluated and all patients were followed for at least 6 months. Results Twenty-three patients (17 males and 6 females) underwent transanal Swenson's procedure. The mean age was 22 ± 5.7 days. Follow-up ranged from 6 to 30 months. No anastomotic leak, retraction, or prolapse was reported. Mild perianal excoriations occurred early in 9 (39%) cases and all responded to medical treatment and disappeared before 2 months postoperatively. Stricture occurred in 2 (8%) patients, enterocolitis in 3 (13%), and constipation in 3 (13%). Conclusion Transanal Swenson's procedure is feasible and can be performed safely in neonates with rectosigmoid HD with good short-term outcomes. Proper patient selection and standard protocol following fine procedural hall-marks and details are keys for optimal results and patient satisfaction.
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Affiliation(s)
- Wesam Mohamed
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | | | - Aly I Shalaby
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Ahmed E Arafat
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Mahmoud M Marei
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Mohamed H Aboulfadl
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Sherif N Kaddah
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Gamal H El Tagy
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Khaled H K Bahaaeldin
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
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Abstract
Dr. Orvar Swenson is best remembered for developing the Swenson pull-through, a technique he developed to treat Hirschsprung's disease. After graduating from Harvard Medical School and beginning his residency at Peter Bent Brigham Hospital, Dr. Swenson observed that patients with Hirschsprung's disease and toxic megacolon resumed normal bowel function after placement of transverse colostomies. His observation led to studying the patency of his patients’ colons using barium enema contrast studies. At the collapsed portion of the colon, he performed rectal biopsies leading to the discovery that the cause of Hirschsprung's disease is that the collapsed portion of the colon lacks the Auerbach plexus. The Swenson pull-through removes this aganglionic portion of the colon and cures the patient. His career grew from there as he traveled to academic institutions teaching his technique. He is remembered fondly for his contributions to pediatric surgery through the restructuring of pediatric surgery departments, pediatric surgery research, and writing and editing multiple volumes of Pediatric Surgery, the standard textbook for pediatric surgeons. He died peacefully in 2012 at the age of 103 years.
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Affiliation(s)
- John J. Newland
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania and
| | - Katerina Dukleska
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania and
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Scott Cowan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania and
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Charles J. Yeo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania and
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Renee Tholey
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania and
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Yokota K, Uchida H, Tainaka T, Tanaka Y, Shirota C, Hinoki A, Kato T, Sumida W, Oshima K, Chiba K, Ishimaru T, Kawashima H. Single-stage laparoscopic transanal pull-through modified Swenson procedure without leaving a muscular cuff for short- and long-type Hirschsprung disease: a comparative study. Pediatr Surg Int 2018; 34:1105-1110. [PMID: 30073481 DOI: 10.1007/s00383-018-4318-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The Soave procedure (SO) is performed most commonly for Hirschsprung disease. SO reduces the risk of injury to the pelvic structures; however, a residual aganglionic muscle cuff could interfere with bowel movement and lead to obstructive enterocolitis. The Swenson procedure is considered ideal in terms of peristalsis. Currently, laparoscopic surgery provides better visualization and facilitates precise dissection, possibly leading to feasible performance of the laparoscopic modified Swenson procedure (SW). We present our operative technique and the efficacy of the SW compared with that of SO. METHODS We retrospectively reviewed the records of 16 and 27 patients who underwent SW and SO, respectively, between 2012 and 2017. RESULTS Operative time, blood loss, length of stay, and frequency of bowel movements showed no significant difference between the two groups. In the SW group, temporary dysuria occurred in one patient, postoperative enterocolitis in two, wound infection in one, and severe perianal excoriation in four, whereas in the SO group, obstructive symptoms occurred in three patients, small-bowel obstruction in one, and severe perianal excoriation in three. The complications and outcomes were comparable between both groups. CONCLUSION Laparoscopic SW was safe and feasible for the short-term follow-up outcomes.
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Affiliation(s)
- Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan.
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan.,Department of Pediatric Surgery, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, Japan
| | - Yujiro Tanaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Takazumi Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Kazuo Oshima
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Kosuke Chiba
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi, 466-8550, Japan
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, Japan
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Nasr A, Haricharan RN, Gamarnik J, Langer JC. Transanal pullthrough for Hirschsprung disease: matched case-control comparison of Soave and Swenson techniques. J Pediatr Surg 2014; 49:774-6. [PMID: 24851768 DOI: 10.1016/j.jpedsurg.2014.02.073] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 02/13/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Both the Swenson and the Soave procedures have been adapted to a transanal approach. The purpose of this study was to compare outcomes following the transanal Swenson and Soave procedures using a matched case control analysis. METHODS A retrospective chart review was performed to identify all transanal Soave and Swenson pullthroughs done at 2 tertiary care children's hospitals between 2000 and 2010. Patients were matched for gestational age, mean weight at time of the operation, level of aganglionosis, and presence of co-morbidities. Student's t-test and chi-squared analysis were performed. RESULTS Fifty-four patients (Soave 27, Swenson 27) had adequate data for matching and analysis. Mean follow-up was 4±1.6 years and 3.2 ±2.7 years for the Soave and Swenson groups, respectively. No significant differences in mean operating time (Soave:191±55, Swenson:167±61 min, p=0.6), overall hospital stay (6±4 vs 7.8±5 days, p=0.7), and number with intra-operative complications (3 vs 4, p=1.0), post-operative obstructive symptoms (6 vs 9, p=0.5), enterocolitis episodes (4 vs 4, p=1.0), or fecal incontinence (0 vs 2, p=0.4) were noted. CONCLUSION After controlling for potential confounders, there were no significant differences in the short and intermediate term outcome between transanal Soave and transanal Swenson pullthrough procedures.
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Affiliation(s)
- Ahmed Nasr
- Division of Pediatric Surgery, Children's Hospital of Eastern Ontario, University of Ottawa.
| | - Ramanath N Haricharan
- Division of Pediatric Surgery, Children's Hospital of Eastern Ontario, University of Ottawa
| | - Julie Gamarnik
- Division of Pediatric Surgery, Children's Hospital of Eastern Ontario, University of Ottawa
| | - Jacob C Langer
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto
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The problematic Soave cuff in Hirschsprung disease: manifestations and treatment. J Pediatr Surg 2014; 49:77-80; discussion 80-1. [PMID: 24439585 DOI: 10.1016/j.jpedsurg.2013.09.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/30/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE Following a Soave pull-through for Hirschsprung disease (HD), some children struggle with obstructive symptoms. We hypothesized that these symptoms could result from a functional obstruction of the pull through caused by the Soave cuff, and that cuff resection might improve bowel emptying. METHODS We reviewed patients referred to our center from 2008 to 2012 with obstructive problems following a Soave pull-through for HD (CCHMC IRB # 2011-2019). Only patients with an obstructing Soave cuff were analyzed. Patients with other reasons for obstruction (anastomotic stricture, transition zone, aganglionic segment) were excluded. RESULTS Thirty-six patients underwent reoperation at our center for obstructive symptoms after an initial Soave pull-through. Seventeen of these patients had a Soave cuff only as the potential source of obstruction. Pre-operative symptoms included enterocolitis (10), constipation (6), and failure to thrive (1). Nine patients (53%) required irrigations to manage distension or enterocolitis pre-operatively. 14/17 patients (82%) had a palpable cuff on rectal exam. Eight patients (47%) had radiographic evidence of a cuff demonstrated by distal narrowing (4) or a prominent presacral space (4). Four children (23%) underwent excision of the cuff only. Thirteen (76%) had removal of the cuff and proximally dilated colon [(average length 7.2cm) (12 performed transanally, and five needed laparotomy as well.)] Post-operatively, episodes of enterocolitis were reduced to zero, and need for irrigation to treat distension was reduced by 50%. Nine patients have voluntary bowel movements, and five are clean on enemas. 3/6 patients with pre-operative constipation or impaction now empty without enemas. (Follow up 1-17months, mean 7months.) CONCLUSIONS Recurrent enterocolitis, constipation, or failure to thrive can indicate a functional obstruction due to a Soave cuff when no other pathologic cause exists. Physical exam or contrast enema can identify a problematic cuff. Reoperation with cuff resection can dramatically improve bowel emptying.
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Abstract
It has been demonstrated that infants with Hirschsprung's disease can be treated with a one-stage laparoscopic resection and coloanal pull-through. However, the feasibility and benefits of performing this operation using robotic technology have not yet been evaluated. We reviewed our experience with 12 infants diagnosed with Hirschsprung's disease and treated with laparoscopic-robotic assisted colonic resection with proctectomy and pull-through using the da Vinci robotic system. Patients were treated at a mean age/weight of 16 weeks/5.5 kg. The average operative time for the robotic procedure was 230 minutes, and average length of stay was 3 days. At discharge, all patients were having regular bowel movements and tolerating a completely oral diet. All patients received early postoperative anorectal dilation and six patients required dilations for an average of 12 weeks after surgery for management of minor rectal strictures. Only two patients developed postoperative enterocolitis with a mean follow-up of 36 months. A robotic approach for performing a Swenson-type resection and pull-through procedure can be performed safely and successfully in young infants. Robotic technology provided superior dexterity and visualization, essential in performing a more complete rectal dissection, thus allowing for a complete proctectomy and eliminating the risk of leaving a segment of aganglionic rectum behind.
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Affiliation(s)
- André Hebra
- Department of Surgery, Division of Pediatric Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Valerie A. Smith
- Department of Surgery, Division of Pediatric Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Aaron P. Lesher
- Department of Surgery, Division of Pediatric Surgery, Medical University of South Carolina, Charleston, South Carolina
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Pini Prato A, Rossi V, Avanzini S, Mattioli G, Disma N, Jasonni V. Hirschsprung's disease: what about mortality? Pediatr Surg Int 2011; 27:473-8. [PMID: 21253751 DOI: 10.1007/s00383-010-2848-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Although significantly decreased during last decades, mortality rate for Hirschsprung's disease still ranges between 1 and 10%. The authors reviewed the main features of patients with Hirschsprung's disease treated in our Institution who died in the period between 1993 and 2010 in order to detect possible risk factors or prevention strategies. METHODS The notes of all patients with Hirschsprung's disease admitted to our Institution between January 1993 and January 2010 were reviewed. All families were interviewed and possible unknown deaths were recorded. We reported demographic data, length of aganglionosis, type and number of associated anomalies, age and type of onset, age and cause of death, chronological relationship between death and pull-through, and all other significant details. RESULTS Eight out of a series of 313 patients with Hirschsprung's disease died during the study period (mortality rate = 2.56%). Six patients were male for a male to female ratio of 3:1. Eleven associated anomalies were detected in five patients, including four congenital anomalies of the kidney and urinary tract, four heart, two central nervous system, and one skeletal malformations. One patient had Down Syndrome and one Cat Eye Syndrome. Two patients were born preterm. All patients had neonatal onset with delayed meconium passage. Five patients had aganglionosis confined to rectosigmoid colon (classic forms), two had total colonic aganglionosis and one had total intestinal aganglionosis. Enterostomy was performed in five patients. Median age at death was 75 days (range 30 days-8 years). The cause of death was enterocolitis in four patients, heart failure in three, and intestinal failure in one. Six patients died before the pull-through. Two patients died postoperatively. All patients but two died at home. CONCLUSIONS Onset and clinical features do correlate with severity. Newborns and infants seem to be more likely to develop serious life-threatening complications, particularly in case of associated cardiovascular malformations. Although enterostomies do not have protective effects over cardiovascular issues, prophylactic stoma should be considered in high-risk patients. Radical treatment (pull-through) should be performed as soon as possible. Alternatively, protected and cautious discharge of newborns with associated heart anomalies is strongly recommended in order to prevent serious and uncontrolled complications, regardless of the presence of a protective enterostomy. Postoperatively, close follow-up appointments are recommended. Families should be acknowledged and educated for prompt recognition and treatment of severe life-threatening complications.
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Affiliation(s)
- Alessio Pini Prato
- Department of Pediatric Surgery, Giannina Gaslini Institute, Largo G. Gaslini, 5, 16148, Genoa, Italy.
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Abstract
The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.
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Affiliation(s)
- Shawn J Rangel
- Department of Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02210, USA.
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The preliminary study of modified Swenson procedure in Hirschsprung disease. J Pediatr Surg 2009; 44:1560-3. [PMID: 19635305 DOI: 10.1016/j.jpedsurg.2008.11.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 11/23/2008] [Accepted: 11/25/2008] [Indexed: 11/22/2022]
Abstract
PURPOSE We have been using the Swenson procedure for more than 3 decades for Hirschsprung disease (HD). Recently, we modified this procedure, leaving the anterior wall below the peritoneal reflection undissected (mSwen). In 2000, we introduced mSwen with laparoscopic guidance (LapmSwen). We hypothesized that (1) omitting anterior wall dissection would not affect postoperative anorectal function, and (2) reduced dissection with better visualization via laparoscopy would reduce operative risks. METHOD Charts of 89 patients with Hirschsprung disease operated on between 1990 through 2005 were retrospectively reviewed. Comparisons between Swen and mSwen, as well as between mSwen and LapmSwen, were analyzed in terms of operating time, blood loss, and complications. RESULTS Mean operating times (minutes) were 312 for Swen, 284 for mSwen (P = .152), and 302 for LapmSwen ( mSwen, P = .218). Mean blood loss (mL) were 64.8 for Swen, 60.3 for mSwen (P = .669), and 8.7 for LapmSwen (as compared to mSwen, P = .001). We noted leakage in 7 Swen, 2 mSwen, and no LapmSwen patients. There were no significant differences between Swen and mSwen, or between mSwen and LapmSwen, in the incidence of enterocolitis, constipation, and soiling. CONCLUSION LapmSwen appeared to be comparable to the standard and modified Swenson procedures in most measures. Operative blood loss may be reduced in the LapmSwen approach.
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Pini Prato A, Gentilino V, Giunta C, Avanzini S, Parodi S, Mattioli G, Martucciello G, Jasonni V. Hirschsprung's disease: 13 years' experience in 112 patients from a single institution. Pediatr Surg Int 2008; 24:175-82. [PMID: 18060412 DOI: 10.1007/s00383-007-2089-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2007] [Indexed: 12/22/2022]
Abstract
Although Hirschsprung's disease is curable, a low mortality and a certain morbidity have been described by several authors. We will present our experience with the treatment of Hirschsprung's disease at Gaslini Children's Hospital. All patients who underwent a pull-through procedure since January 1993 were included. Data were obtained from a comprehensive questionnaire and from the revision of the notes. The results were subsequently described and compared with regard to age and length of aganglionosis. A total of 151 patients underwent a pull-through. One hundred and twelve of these patients completed the forms and were reviewed. Eighty patients had a classic form, 22 an ultralong. Complications occurred in 28 patients (25%). Postoperative enterocolitis was complained by 25 patients (13% colonic and 59% ultralong forms) and constipation by 15 (equally distributed). Excellent to good continence was experienced by 84% of patients with classic forms and by 68% of patients with ultralong forms. A clear improving trend during growth was evident for patients with ultralong forms. Psychological self-acceptance, patients' perspective and cosmetic results proved to be significantly better for patients with classic forms of the disease. Our study confirmed the complications and long-term sequelae that patients with Hirschsprung's can experience. Early diagnosis can minimise morbidity and mortality and prompt and adequate treatment can reduce the incidence of postoperative complications. The parents should be acknowledged regarding the progressive improvements of function that patients gain during growth, particularly in case of ultralong forms, thus strengthening the need for continuative care and close follow-up.
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Affiliation(s)
- Alessio Pini Prato
- Department of Pediatric Surgery, IRCCS G. Gaslini Institute, Largo G. Gaslini, 5, 16147, Genoa, Italy.
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Nasr A, Langer JC. Evolution of the technique in the transanal pull-through for Hirschsprung's disease: effect on outcome. J Pediatr Surg 2007; 42:36-9; discussion 39-40. [PMID: 17208538 DOI: 10.1016/j.jpedsurg.2006.09.028] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The transanal pull-through has become the standard operation for Hirschsprung's disease in many pediatric surgical centers. Over the past 8 years, we have modified our technique by leaving a short-rather than a long-rectal cuff and by doing routine intraabdominal colonic biopsies through an umbilical incision before beginning the anal dissection. The aim of this study was to determine if these modifications have changed the outcome for children undergoing this operation. METHODS A retrospective cohort study of all patients who underwent transanal pull-through by a single surgeon between 1997 and 2005 was conducted. RESULTS There were 23 children who had a long cuff (10-15 cm) and 22 who had a short cuff (<2 cm). The short cuff group tended to be younger (25 +/- 23 vs 139 +/- 67 days; P < .05) and smaller (3.5 +/- 0.7 vs 6.0 +/- 2.7 kg; P < .05) at the time of surgery. The operating time was shorter (167 vs 186 minutes; P = .05) in the short cuff group. Outcomes were improved in the short cuff group, as evidenced by decreased hospital stay (1.9 +/- 0.6 vs 2.7 +/- 0.9; P < .05), decreased incidence of enterocolitis (9% vs 30%; P = .1), and lower incidence of narrowing requiring daily dilatations (5% vs 30%; P < .05). Preliminary colonic biopsy was performed on 18 of the 45 patients. This had no significant effect on narcotic use (66% vs 70%; P = .8) and did not increase operating time (174 +/- 31 vs 179 +/- 34 minutes; P = .6). Hospital stay was shorter in the umbilical biopsy group (1.9 +/- 0.6 vs 2.6 +/- 0.9 days; P = .006). CONCLUSION Results of the transanal pull-through have improved likely as a result of a combination of experience and use of a shorter rectal muscular cuff. The use of a preliminary colonic biopsy through an umbilical incision has not increased postoperative pain, prolonged operative time, or lengthened hospital stay.
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Affiliation(s)
- Ahmed Nasr
- Division of General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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