Duhamel operation vs neonatal transanal endorectal pull-through procedure for Hirschsprung disease: which are the changes for pathologists?

Comparison between two minimally invasive techniques for Hirschsprung disease: transanal endorectal pull-through (TERPT) versus laparoscopic-TERPT

INTRODUCTION

Surgical treatment for Hirschsprung disease (HD) has recently evolved into different minimally invasive techniques. The aim of the present study is to compare results from two different minimal invasive approaches, transanal endorectal pull-through (TERPT) and laparoscopic-assisted endorectal pull-through (LA-TERPT).

METHODS

Patients have been divided into two groups according to surgical technique. Data of HD patients treated by TERPT and those treated by LA-TERPT, respectively, performed at two different centers from January 2007 to December 2017, were retrospectively collected. Patients with aganglionosis confined to the recto-sigmoid colon with a minimum follow-up period of 4 years have been included. Demographic, clinical, surgical and functional outcome data were reviewed for each group using Chi-square and Fisher tests (statistical differences were considered for p < 0.05).

RESULTS

Among patients treated for HD in the two centers during the study period, 65 met the inclusion criteria (37 TERPT group and 28 LA-TERPT group). No differences regarding demographic and clinical data were observed between the two groups. Operative time was longer in the LA-TERPT group (p < 0.001). Time to start oral feeding was faster in the TERPT group while hospital stay was similar between the two groups. Three patients of the TERPT group required an additional abdominal approach. The rate of early complications was higher in the TERPT group. Long-term bowel function was assessed in 31 patients for the TERPT group and 24 patients for the LA-TERPT group. Outcomes showed that the bowel functional outcome was good (BFS ≥ 17) in 55% (n = 17) of TERPT group and 54% of LA-TERPT group (p = 0.97), moderate (BFS 12 to 16) in 16% (n = 5) and 33% (n = 8), respectively (p = 0.24), and poor in 29% (n = 9) and 13% (n = 3), respectively (p = 0.23).

CONCLUSIONS

Both TERPT and LA-TERPT techniques should be considered safe and feasible for the treatment of HD patients. TERPT patients present faster time to return to normal bowel function while LA-TERPT patients have slightly lower incidence of postoperative complications. Long-term functional outcomes are similar between the two groups.

LEVEL OF EVIDENCE

III.

The microenvironment in the Hirschsprung's disease gut supports myenteric plexus growth

INTRODUCTION

The transplantation of neural crest derived stem cells (NCSC) is a potent alternative for the treatment of Hirschsprung's disease (HSCR). Cells to be transplanted should find an appropriate microenvironment to survive and differentiate. Influences of HSCR-smooth-muscle-protein extracts upon isolated myenteric plexus cells, dissociated dorsal root ganglia and NCSC were studied in vitro to investigate the quality of this microenvironment effects.

METHODS

Postnatal human gut from children undergoing colonic resection due to HSCR was divided in segments. Smooth muscle was dissected and homogenized. Glial-cell-line-derived-neurotrophic-factor (GDNF) and transforming-growth-factor-β-1 (TGFβ-1) concentration were measured in the homogenates from the individual segment using ELISA. Myenteric plexus and dissociated dorsal root ganglia (DRG) cultures, as well as NCSCs were exposed to protein extracts derived from ganglionic and aganglionic HSCR segments, and their effect upon neurite outgrowth, survival, and branching was evaluated.

RESULTS AND CONCLUSIONS

The amount of the factors varied considerably between the individual segments and also from patient to patient. Four major expression patterns could be detected. While all extracts tested lead to a significant increase in neurite outgrowth compared to the control, extracts from proximal segments tended to have more prominent effects. In one experiment, extracts from all individual segments of a single patient were tested. Neurite outgrowth, neuronal survival, and branching pattern varied from segment to segment, but all HSCR-muscle-protein extracts increased neuronal survival and network formation. Smooth muscle protein from aganglionic bowel supports the survival and outgrowth of myenteric neurons and NCSCs and is so an appropriate target for neural stem cell treatment.

Smooth muscle proteins from Hirschsprung's disease facilitates stem cell differentiation

BACKGROUND AND AIMS

The transplantation of neural crest derived stem cells (NCSC's) is a potent alternative for the treatment of Hirschsprung's disease (HSCR). Cells to be transplanted should find an appropriate microenvironment to survive and differentiate. To investigate the quality of this microenvironment, effects of HSCR-smooth-muscle-protein extracts upon NCSC's were studied in vitro.

METHODS

Postnatal human gut from children undergoing colonic resection due to HSCR was divided in segments. Smooth muscle was dissected and homogenized. Glial-cell-line-derived-neurotrophic-factor (GDNF) concentration was measured in the homogenates from the individual segment using ELISA. NCSC's were exposed to protein extracts derived from ganglionic and aganglionic HSCR segments, and their effect upon neurite outgrowth, survival and branching was evaluated.

RESULTS

The amount of the factors varied considerably between the proximal and distal segments, and also from patient to patient. While extracts from proximal segments tended to have more prominent effects, all HSCR-muscle-protein extracts increased neuronal survival and network formation.

CONCLUSION

Muscle protein from aganglionic bowel supports the survival and outgrowth of NCSC's and is so an appropriate target for neural stem cell treatment.

What is the most common complication after one-stage transanal pull-through in infants with Hirschsprung's disease?

BACKGROUND

Hirschsprung's disease (HD) is a relatively common congenital disease that could be suspected by clinical symptoms, abdominal plain X-ray, and finally diagnosed by rectal biopsy. In 80% cases, rectosigmoid junction is involved. Recently, one-stage transanal pull-through (TAPT) procedure has been popular and may have several complications.

METHODS AND PATIENTS

During a 4-year period, 86 infants (28 girls, 58 boys) with mean age 8 days (3-33) and clinically suspected to HD were admitted in our center. HD was proved by rectal biopsy. All patients after full bowel preparation and rectal washout were candidates for TAPT operation. A Swenson-like procedure was performed and the anastomosis was done between the well blood supply ganglionic colon and the rectum at 1 cm above dentate line. Interrupted suture with 5-0 Vicryl was used. Nelaton tube (12 F) inserted in the pelvis via transprineal for drainage of blood or collection. From February 2008 in 30 cases, prophylactic Hegar dilatation was performed 2 weeks after operation.

RESULTS

Anal stricture in 12 cases (14%) was treated by anal dilation in 10 cases and 2 cases corrected by surgical management. Entrocolitis in 4 cases (5%) was treated by medical management. In two cases, retrocolic abscess had spontaneous drainage via tube drain. There was no anastomotic stricture after starting prophylactic anal bouginage.

CONCLUSION

TAPT has many advantages, low complications and the results are excellent. It seems the most common complication is anastomotic stricture that responds well to prophylactic bouginage. We recommend prophylactic anal bouginage with Hegar probe at 2 weeks after operation. Long-term follow-up is needed to evaluate the outcomes of our operations.